2021 Provider Manual

PROV16-NE-00025 1 Table of Contents WELCOME ...... 4 About Us ...... 4 About This Manual ...... 4 Key Contacts ...... 4 Populations Served ...... 5 VERIFYING ELIGIBILITY ...... 7 Member Identification Card ...... 7 Online Resources ...... 8 Secure Website ...... 8 Lock-in ...... 9 GUIDELINES FOR PROVIDERS ...... 10 Medical Home Model ...... 10 Providers (PCP) ...... 10 Member Panel Capacity ...... 11 Reimbursement to FQHC’s and RHC’s ...... 13 Referrals ...... 14 Specialist Responsibilities ...... 15 Mainstreaming ...... 16 Appointment Accessibility and Access Standards ...... 16 Minimum PCP Hours ...... 18 Covering Providers ...... 18 Telephone Arrangements ...... 19 24-Hour Access ...... 19 Responsibilities ...... 20 Advance Directives ...... 20 Voluntarily Leaving the Network ...... 21 CULTURAL COMPETENCY ...... 22 BENEFIT EXPLANATIONS AND LIMITATIONS ...... 24 Covered Services ...... 24 Special Services to Assist Members ...... 27 Value Added Services ...... 28 NETWORK DEVELOPMENT AND MAINTENANCE ...... 32 Non-Discrimination ...... 33 Tertiary Care ...... 33 MEDICAL MANAGEMENT ...... 34 Integrated Care ...... 34 Complex Care Management Program ...... 35 Early and Periodic Screening, Diagnostic & Treatment ...... 41 Emergency Care Services ...... 42 Medical Necessity ...... 43 Utilization Management ...... 43 Clinical Practice Guidelines ...... 55 ...... 57 Preferred Drug List (PDL) ...... 57 Compounds ...... 57 Pharmacy and Therapeutics Committee (P&T) ...... 58 Unapproved Use of Preferred Medication ...... 58

2 Prior Authorization Process ...... 58 Newly Approved Products ...... 59 Step Therapy ...... 59 Prospective DUR Response Requirements ...... 60 Injectable Drugs...... 60 Biopharmaceuticals and Injectables...... 60 Dispensing Limits, Quantity Limits and Age Limits ...... 61 Mandatory Generic Substitution ...... 61 Over-The-Counter Medications ...... 61 Working With the Pharmacy Benefit Manager (PBM) ...... 61 Pharmacy Portal and Provider Links ...... 63 PROVIDER RELATIONS AND SERVICES ...... 64 Provider Relations ...... 64 Provider Services ...... 64 CREDENTIALING AND RE-CREDENTIALING ...... 65 Overview ...... 65 Which Providers Must be Credentialed? ...... 65 Information Provided at Credentialing ...... 66 Credentialing Committee ...... 67 Re-Credentialing...... 67 Right to Review and Correct Information ...... 68 Right to Be Informed of Application Status...... 68 Right to Appeal Adverse Credentialing Determinations...... 68 Disclosure of Ownership and Control Interest Statement ...... 69 RIGHTS AND RESPONSIBILITIES ...... 70 Member Rights ...... 70 Member Responsibilities ...... 71 Provider Rights ...... 72 Provider Responsibilities ...... 72 PROVIDER GRIEVANCE PROCESS ...... 75 Member Grievance and Appeal Process ...... 75 FRAUD, WASTE AND ABUSE ...... 79 Post Processing Claims Audit ...... 80 Suspected Inappropriate Billing ...... 80 QUALITY IMPROVEMENT ...... 81 Program Structure ...... 81 Practitioner Involvement ...... 82 Quality Assessment and Performance Improvement Program Scope and Goals ...... 82 Safety and Quality of Care ...... 83 Performance Improvement Process...... 83 Healthcare Effectiveness Data and Information Set (HEDIS) ...... 84 MEDICAL RECORDS REVIEW ...... 86 Required Information ...... 86 Medical Records Release ...... 87 Medical Records Transfer for New Member ...... 87 Federal and State Laws Government the Release of Information ...... 87

3 WELCOME Welcome to Nebraska Total Care, and thank you for being part of our network of physicians, and other healthcare professionals. We look forward to working with you to improve the health of our state, one person at a time.

ABOUT US Nebraska Total Care is a Health Plan awarded a contract with the Nebraska Department of Health and Human Services to provide healthcare services to a portion of Medicaid members.

ABOUT THIS MANUAL This manual contains comprehensive information about Nebraska Total Care operations, benefits, billing, and policies and procedures. The most up-to-date version can always be viewed from our website NebraskaTotalCare.com. You will be notified of updates via notices posted on our website and/or in Explanation of Payment (EOP) notices.

KEY CONTACTS The following chart includes several important telephone and fax numbers available to your office. When calling Nebraska Total Care, please have the following information available: • NPI (National Provider Identifier) number • Tax ID Number (TIN) number • Member’s Nebraska Total Care ID number or Medicaid ID number

Department Telephone Number Fax Number Provider Services 1-844-385-2192, Nebraska Relay 1-844-305-8372 Monday – Friday Service 711 7 a.m. to 8 p.m. CST Member Services 1-844-385-2192, Nebraska Relay 1-844-305-8372 Monday – Friday Service 711 8 a.m. to 5 p.m. CST Medical Management 1-844-385-2192, Nebraska Relay Admissions: Service 711 1-844-360-9454 Case Management: 1-844-340-4888 Concurrent Review: 1-844-845-5086 Prior Authorization: 1-844-774-2363 24 Hour Nurse Advice Line 1-844-385-2192, Nebraska Relay NA (24/7 Availability) Service 711 Pharmacy - RxAdvance 1-800-974-5268 NA Nebraska Medicaid Eligibility 402-471-9580 NA System (NMES) 1-800-642-6092

4 POPULATIONS SERVED Medicaid populations who are mandated to participate in the Nebraska Medicaid managed care program include: • Families, children, and pregnant women eligible for Medicaid under Section 1931 of the Social Security Act or related coverage groups. • Children, adults, and related populations who are eligible for Medicaid due to blindness or disability. • Medicaid beneficiaries who are age 65 or older and not members of the blind/disabled population or members of the Section 1931 adult population. • Low-income children who are eligible to participate in Medicaid in Nebraska through Title XXI, the Children’s Health Insurance Program (CHIP). • Medicaid beneficiaries who are receiving foster care or subsidized adoption assistance (Title IV-E), are in foster care, or are otherwise in an out-of-home placement. • Medicaid beneficiaries who participate in a HCBS Waiver program. This includes adults with intellectual disabilities or related conditions; children with intellectual disabilities and their families, aged persons, and adults and children with disabilities; members receiving targeted case management through the DHHS Division of Developmental Disabilities; Traumatic Brain Injury Waiver participants; and any other group covered by the State’s 1915(c) waiver of the Social Security Act. • Women who are eligible for Medicaid through the Breast and Cervical Cancer Prevention and Treatment Act of 2000 (Every Woman Matters). • Medicaid beneficiaries for the period of retroactive eligibility, when mandatory enrollment for managed care has been determined. • Members eligible during a period of presumptive eligibility.

Heritage Health Adult (HHA) Expansion Population Effective October 1, 2020, the Nebraska Medicaid Managed Care population will be expanded to include adult members with an income level up to 138% of the federal poverty level under the provisions of the Patient Protection and Affordable Care Act. Retroactive benefits will remain available under the same conditions as today. The HHA Expansion Program will consist of two benefit tiers: Basic and Prime, until September 30, 2021.

Effective October 1, 2021, all HHA expansion members enrolled in the program, regardless of previous benefit tier category, will receive the full benefits package which includes all Medicaid covered services.

Eligible Nebraskans will have a comprehensive benefits package that includes the following services: • Ambulatory care • Emergency care • Hospitalization • Maternity and Newborn care • Mental Health and Substance Use Disorder services, including integrated Behavioral Health • Prescription Drugs • Rehabilitative & Habilitative services and devices • Laboratory services • Preventive, wellness and chronic disease management

5 • Other services such as: long-term care, non-emergency medical transportation and durable medical equipment (DME) • Dental Services • Vision Services • Over-the-counter medications

[MH1]Excluded Populations Within the groups identified above, the following categories of beneficiaries are excluded from managed care: • Aliens who are eligible for Medicaid for an emergency condition only. • Beneficiaries who have excess income or who are required to pay a premium, except those who are continuously eligible due to a share of cost obligation to a facility or for HCBS Waiver services. • Beneficiaries who have received a disenrollment or waiver of enrollment. • Participants in the Program for All-Inclusive Care for the Elderly. • Beneficiaries with Medicare coverage where Medicaid only pays co-insurance and deductibles. • Inmates of public institutions.

6 VERIFYING ELIGIBILITY To verify member eligibility, please use one of the following methods: • Log on to our secure provider portal at NebraskaTotalCare.com. Using our secure provider website, you can check member eligibility. You can search by date of service and either of the following: Member name and date of birth, or member Medicaid ID and date of birth. • Call our automated member eligibility IVR system. Call 1-844-385-2192 from any touch-tone phone and follow the appropriate menu options to reach our automated member eligibility-verification system 24 hours a day. The automated system will prompt you to enter the member Medicaid ID and the month of service to check eligibility. • Call Nebraska Total Care Provider Services. If you cannot confirm a member’s eligibility using the methods above, call our toll-free number at 1-844-385-2192, Nebraska Relay Service 711. Follow the menu prompts to speak to a Provider Services Representative to verify eligibility before rendering services. Provider Services will need the member name, member Medicaid ID, and member date of birth to verify eligibility. Through Nebraska Total Cares’ secure provider portal, Primary Care Providers (PCPs) are able to access a list of eligible members who have selected their services or were assigned to them. The Patient List is reflective of all demographic changes made within the last 24 hours. The list also provides other important information including date of birth and indicators for whose claims data show a gap in care, such as a missed Early Periodic Screening, Diagnosis and Treatment (EPSDT) exam. To view this list, log on to NebraskaTotalCare.com. Eligibility changes can occur throughout the month and the Patient List does not prove eligibility for benefits or guarantee coverage. Use one of the above methods to verify member eligibility on the date of service. All new Nebraska Total Care members receive a Nebraska Total Care member ID card. Members will keep their state issued ID card to receive services not covered by the plan (such as dental).A new card is issued only when the information on the card changes, if a member loses a card or if a member requests an additional card. Possession of a member ID card is not a guarantee of eligibility. Use one of the above methods to verify member eligibility on the date of service.

MEMBER IDENTIFICATION CARD Whenever possible, members should present both their Nebraska Total Care member ID card, Nebraska Medicaid ID card, and a photo ID each time services are rendered by a provider. If you are not familiar with the person seeking care as a member of our health plan, please ask to see photo identification. If you suspect fraud, please contact Provider Services at 1-844-385-2192, Nebraska Relay Service 711 immediately. Members must also keep their state-issued Medicaid ID card in order to receive benefits not covered by Nebraska Total Care.

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ONLINE RESOURCES Our website can significantly reduce the number of telephone calls providers need to make to the health plan. Utilizing the website allows immediate access to current provider and member information 24 hours, seven days a week. Please contact your Provider Relations Representative or our Provider Services department at 1-844-385-2192, Nebraska Relay Service 711 with any questions or concerns regarding the website. Nebraska Total Care website is located at NebraskaTotalCare.com. Providers can find the following information on the website: • Prior Authorization Code Check Tool • Forms • Nebraska Total Care Plan News • Clinical Guidelines • Provider Bulletins • Contract Request Forms • Provider Representative Contact Information • Provider Training Manual • Provider Education Training Schedule

SECURE WEBSITE Nebraska Total Care web portal services allow providers to check member eligibility and benefits, submit and check status of claims, request authorizations and send messages to communicate with Nebraska Total Care staff. All providers and their office staff have the opportunity to register for our secure provider website in just 4-easy steps. Here, we offer tools that make obtaining and sharing information easy! It is simple and secure! Go to NebraskaTotalCare.com to register. On the home page, select the Login link on the top right to start the registration process.

8 Through the secure site you can: • Check member eligibility • View members’ health record • View the PCP panel (patient list) • View and submit claims and adjustments • Verify claim status • Verify proper coding guidelines. • View payment history • View and submit authorizations • Verify authorization status • View member health record • View member gaps in care • Contact us securely and confidentially • Add/Remove account users • Determine payment/check clear dates • Add/Remove TINs from a user account • EPSDT Reports • Send a member referral to the Care Management Team • View PCP Quality Incentive Report • View and print Medical Explanation of Payment Please contact a Provider Relations Representative for a tutorial on the secure provider portal.

LOCK-IN

Restricted Services Nebraska Total Care will identify members for care management activities, assign a care manager, and will offer care management services. Should an individual decline care management participation, Nebraska Total Care will document this within the member’s record. Lock-in restriction can be any of the following, determined by Nebraska Total Care: • No Lock-in • One Pharmacy • One Primary Practitioner and One Pharmacy • One Primary Practitioner, One Pharmacy and One Hospital • One Prescribing Physician and One Pharmacy • Emergency Medical Services will be handled on a case-by-case basis.

9 GUIDELINES FOR PROVIDERS

MEDICAL HOME MODEL Nebraska Total Care is committed to supporting its network providers in achieving recognition as medical homes and will promote and facilitate the capacity of primary care practices to function as medical homes by using systematic, patient-centered and coordinated care management processes. Nebraska Total Care will support providers in obtaining either NCQA’s Physician Practice Connections®-Patient-Centered Medical Home (PPC®- PCMH) recognition or the Joint Commission’s Primary Care Medical Home Option for Ambulatory Care accreditation. The purpose of the medical home program is to promote and facilitate a medical home model of care that will provide better healthcare quality, improve self-management by members of their own care and reduce avoidable costs over time. Nebraska Total Care will actively partner with our providers, with community organizations, and groups representing our members to increase the numbers of providers who are recognized as medical homes (or committed to becoming recognized). Nebraska Total Care has dedicated resources to ensure its providers achieve the highest level of medical home recognition with a technical support model that will include: • Readiness survey of contracted providers • Education on the process of becoming certified • Resource tools and best practices Our secure provider portal offers tools to help support PCMH accreditation elements. These tools include: • Online Care Gap Notification • Member Panel Roster including member detail information For more information on the Medical Home model or to how to become a Medical Home, contact your Provider Relations Representative.

PRIMARY CARE PROVIDERS (PCP) The Primary Care Provider (PCP) is the cornerstone of Nebraska Total Care service delivery model. The PCP serves as the “Medical Home” for the member. The Medical Home concept assists in establishing a member-provider relationship, supports continuity of care, patient safety, leads to elimination of redundant services and ultimately more cost effective care and better health outcomes. Nebraska Total Care offers a robust network of primary care providers. This ensures every member has access to a Medical Home within the required travel distance standards (two PCPs within 30-mile radius of each members’ personal residence in urban counties; one PCP within 45 miles of the personal residences of members in rural counties; and one PCP within 60 miles of the personal residences of members in frontier counties). We request that PCPs inform our Member Service department when a Nebraska Total Care member misses an appointment so we can monitor and provide outreach to the member on the importance of keeping appointments. This will assist our providers in reducing their missed appointments and reduce the inappropriate use of Emergency Room services.

10 Provider Types That May Serve As PCPs Specialty types who may serve as PCPs include: • Family Practitioner • General Practitioner • Internist • Pediatrician • Obstetrician or Gynecologist (OB/GYN) • Advanced practice nurses (APNs) and physician assistants may also serve as PCPs when they are practicing within the scope and requirements of their license Members with disabling conditions, chronic illnesses or Children with Special Needs may request that their PCP be a specialist. The designation of the specialist as a PCP must be in consultation with the current PCP, member, and the specialist. The specialist serving as a PCP must agree to provide or arrange for all primary care, including routine preventive care, and provide those specialty medical services consistent with the member’s disabling condition, chronic illness or Special Health Care Needs in accordance with the PCP responsibilities included in this manual.

MEMBER PANEL CAPACITY All PCPs reserve the right to state the number of members they are willing to accept into their panel. Nebraska Total Care DOES NOT guarantee any provider will receive a certain number of members. If a PCP declares a specific capacity for his/her practice and wants to make a change to that capacity, the PCP must contact Nebraska Total Care Provider Services at 1-844-385-2192, Nebraska Relay Service 711. A PCP shall not refuse to treat members as long as the physician has not reached their requested panel size. Providers shall notify Nebraska Total Care in writing at least 45 days in advance of his or her inability to accept additional Medicaid covered persons under Nebraska Total Care agreements. In no event shall any established patient who becomes a Nebraska Total Care member be considered a new patient. Providers have the right to request a member’s disenrollment from his/her panel and be reassigned to a new PCP. Nebraska Total Care facilitates these requests in a manner that continues to provide members with required healthcare in an environment acceptable to both the member and their provider. Providers are able to request the full policy for review as necessary. Acceptable reasons for disenrollment: • Incompatibility of the PCP/patient relationship • Inability to meet the medical needs of the Member Unacceptable reasons for disenrollment: • A change in the member's health status need for treatment • A member's utilization or under-utilization of medical services

11 • A member's diminished mental capacity disruptive behavior that results from the member's special health care needs unless the behavior impairs the ability of the PCP to furnish services to the Member or others • Transfer requests shall not be based on race, color, national origin, handicap, age or gender The provider shall make the change for request in writing. The Plan has authority to approve all transfers. The initial Provider must serve the member for a minimum of 30 days, or until the new Provider begins serving the member, barring ethical or legal issues. The Member has the right to Appeal such a transfer in the formal Appeals process.

PCP Assignment Nebraska Total Care members have the freedom to choose a PCP from our comprehensive provider network. Within 10 days of enrollment, Nebraska Total Care will send new members a letter encouraging them to select a PCP. For those members who have not selected a PCP during enrollment or within 30 calendar days of enrollment, Nebraska Total Care will use a PCP auto-assignment algorithm to assign an initial PCP. Pregnant women should choose a pediatrician, or other appropriate PCP, for the care of their newborn baby before the beginning of the last trimester of gestation. In the event that the pregnant member does not select a pediatrician or other appropriate PCP, Nebraska Total Care will contact pregnant members a minimum of 60 calendar days prior to the expected delivery date to encourage mothers to choose a PCP for their newborns. In the event a PCP is not selected, Nebraska Total Care will give the member a minimum of 14 days after the birth to select a PCP prior to auto assignment.

Primary Care Provider (PCP) Responsibilities PCP’s responsibilities include, but are not limited, to the following: • Establish and maintain hospital-admitting privileges sufficient to meet the needs of all linked members with at least one hospital within the required network adequacy distance requirements. • Manage the medical and healthcare needs of members to assure that all medically necessary services are made available in a culturally competent and timely manner while ensuring patient safety at all times including members with special needs and chronic conditions. • Educate members on how to maintain healthy lifestyles and prevent serious illness. • Provide screening, well care and referrals to community health departments and other agencies in accordance with DHHS provider requirements and public health initiatives. • Maintain continuity of each member’s health care by serving as the member’s medical home. • Offer hours of operation no less than the hours of operating hours offered to commercial members or comparable to commercial health plans if the PCP does not provide health services to commercial members. • Provide referrals for specialty and subspecialty care and other medically necessary services, which the PCP does not provide. • Ensure follow-up and documentation of all referrals including services available under the State’s fee-for-service program.

12 • Collaborate with Nebraska Total Care’s care management program as appropriate to include, but not limited to, performing member screening and assessment, development of plan of care to address risks and medical needs, linking the member to other providers, medical services, residential, social, community and other support services as needed for physical or behavioral illness. • Maintain a current and complete medical record for the member in a confidential manner, including documentation of all services and referrals provided to the member, including but not limited to, services provided by the PCP, specialists, and providers of ancillary services. • Adhere to the EPSDT periodicity schedule for members under age 21. • Follow established procedures for coordination of in-network and out-of-network services for members, including obtaining authorizations for selected inpatient and selected outpatient services as listed on the current prior authorization list, except for emergency services up to the point of stabilization; as well as coordinating services the member is receiving from another health plan during transition of care. • Share results of identification and assessment for any member with special health care needs with another health plan to which a member may be transitioning or has transitioned so services are not duplicated. • Transfer members’ medical records to the receiving provider upon the change of PCP at the request of the new PCP and as authorized by the member within 30 calendar days of the date of the request. • Allows use of practitioner performance data for Nebraska Total Care quality improvement activities. • Maintain the confidentiality of member information and medical records. • Actively participate in and cooperate with all Nebraska Total Care quality initiatives and activities to improve quality of care and services to member experience. Cooperation includes collection and evaluation of data. • Provide notice to Nebraska Total Care of any updates necessary to the physician directory such as new address, new phone number, or change in group practice affiliation at least thirty (30) days prior to the effective date of such changes, when possible.

REIMBURSEMENT TO FQHC’S AND RHC’S Nebraska Total Care will reimburse FQHCs and RHCs in accordance with 471 NAC Chapters 29 and 34. Nebraska Total Care will not enter into alternative reimbursement arrangements with FQHCs or RHCs, if initiated by the FQHC or RHC, without prior approval from MLTC. If Nebraska Total Care is unable to contract with an FQHC or RHC within PCP access distance standards provided by MLTC, Nebraska Total Care is not required to reimburse that FQHC or RHC for out-of-network services without prior approval unless: • The medically necessary services are required to treat an emergency medical condition. • FQHC/RHC services are not available through a minimum of one (1) MCO within MLTC’s established travel standards. Nebraska Total Care may stipulate that reimbursement is contingent on receiving a clean claim and all medical information required to update the member’s medical record.

13 REFERRALS Nebraska Total Care prefers that the PCP coordinate healthcare services; however, PCPs are encouraged to refer a member when medically necessary care is needed that is beyond the scope of what the PCP can provide. Nebraska Total Care has the ability to arrange standing or frequency-based prior-authorizations as determined by the member’s course of treatment or regular care monitoring plan as appropriate for the member’s condition or medical needs. Obtaining referrals from the PCP are not required as a condition of payment for services by Nebraska Total Care. The PCP must obtain prior authorization from Nebraska Total Care for referrals to certain specialty providers as noted on the prior authorization list. All out-of-network services require prior authorization as further described herein except for family planning, emergency room, and tabletop x-ray services. A provider is also required to promptly notify Nebraska Total Care when prenatal care is rendered. Nebraska Total Care encourages specialists to communicate to the PCP the need for a referral to another specialist. This allows the PCP to better coordinate their members’ care and become aware of the additional service request. Providers are prohibited from making referrals for designated health services to healthcare entities with which the provider or a member of the providers’ family has a financial relationship.

Provider Requirements • Only provide health care applicable to provider’s license. • Schedule outpatient follow up and/or continuing treatment prior to discharge for all members that have received inpatient psychiatric services. • Ensure outpatient treatment occurs within seven (7) days from the date of discharge. • Contact Nebraska Total Care Member Services when a member has missed an appointment so we can provide outreach and attempt to reschedule. • Maintain the confidentiality of member information and medical records. • Actively participate in and cooperate with all Nebraska Total Care quality initiatives and activities to improve quality of care and services to member experience. Cooperation includes collection and evaluation of data. • Allow use of practitioner performance data for Nebraska Total Care quality improvement activities. • Quality Mental for Community Services (QMHP-CS) the requirement minimums for a QMHP-CS are as follows:

o Demonstrated competency in the work to be performed; and o Bachelor’s degree from an accredited college or university with a minimum number of hours that is equivalent to a major in psychology, social work, , nursing, rehabilitation, counseling, sociology, human growth and development, physician assistant, gerontology, special education, educational psychology, early childhood education, or early childhood intervention; or be a Registered Nurse (RN).

14 • A qualified Provider of mental health targeted care management must:

o Demonstrated competency in the work performed; and o Possess a bachelor’s degree from an accredited college or university with a minimum number of hours that is equivalent to a major in psychology, social work, medicine, nursing, rehabilitation, counseling, sociology, human growth and development, physician assistant, gerontology, special education, educational psychology, early childhood education, or early childhood intervention; or be a registered nurse (RN).

SPECIALIST RESPONSIBILITIES Nebraska Total Care encourages specialists to communicate to the PCP the need for a referral to another specialist, rather than making such a referral themselves. This allows the PCP to better coordinate the members’ care and ensure the referred specialty physician is a participating provider within the Nebraska Total Care network and that the PCP is aware of the additional service request. The specialty physician may order diagnostic tests without PCP involvement by following Nebraska Total Care referral guidelines. Emergency admissions will require notification to Nebraska Total Care’s Medical Management Department within the standards set forth in the Utilization Management section of this manual. All non-emergency inpatient admissions require prior authorization from Nebraska Total Care. The specialist provider must: • Maintain contact with the PCP • Obtain authorization from Nebraska Total Care Medical Management Department (“Medical Management”) if needed before providing services • Coordinate the member’s care with the PCP • Provide the PCP with consult reports and other appropriate records within five business days • Be available for or provide on-call coverage through another source 24 hours a day for management of member care • Maintain the confidentiality of member information and medical information • Actively participate in and cooperate with all Nebraska Total Care quality initiatives and activities to improve quality of care and services to member experience. Cooperation includes collection and evaluation of data • Allows use of practitioner performance data for Nebraska Total Care quality improvement activities. Nebraska Total Care providers should refer to their contract for complete information regarding their obligations and mode of reimbursement. Such reimbursement shall be no less than the published Medicaid fee-for-service rate in effect on the date of service or its equivalent (such as a DRG case rate), unless mutually agreed to by both Nebraska Total Care and the provider in the provider contract. Nebraska Total Care providers should refer to their contract for complete information regarding providers’ obligations or contact their Provider Relations Representative with any questions or concerns.

15 MAINSTREAMING Nebraska Total Care considers mainstreaming of its members an important component of the delivery of care. Nebraska Total Care expects its participating providers to treat members without regard to pay source, race, color, creed, sex, religion, age, national origin (including those with limited English proficiency), ancestry, marital status, sexual preference, gender identity, health status, genetic information, income status, program membership or physical or behavioral disabilities except where medically indicated. Examples of prohibited practices include: • Denying a member a covered service or availability of a facility. • Providing a Nebraska Total Care member a covered service that is different or in a different manner, or at a different time or at a different location than to other “public” or private pay members (examples: different waiting rooms or appointment times or days), except where medically necessary. • Subjecting a member to segregation or separate treatment in any manner related to the receipt of any covered service; or restricting a member in any way in his/her enjoyment of any advantage or privilege enjoyed by others receiving any covered service. • Assigning times or places for provision of services based on the race, color, creed, religion, age, gender, national origin, ancestry, marital status, sexual orientation, gender identity, income status, Medicaid membership, or physical or mental illnesses of the participants served.

APPOINTMENT ACCESSIBILITY AND ACCESS STANDARDS Nebraska Total Care follows the accessibility requirements set forth by applicable regulatory and accrediting agencies. Nebraska Total Care monitors compliance with these standards on an annual basis and will use the results of appointment standards monitoring to first, ensure adequate appointment availability and second, reduce unnecessary emergency room utilization.

Primary Care Provider scheduling PCP- Type of appointment Scheduling time-frame Emergency services Immediate and available twenty-four (24) hours a day, seven days a week Urgent care The same day and be provided by the PCP or as arranged by the MCO. Routine sick care Within seventy-two (72) hours of presentation or sooner if the member’s medical condition(s) deteriorate into an urgent or emergent situation. Routine well care Within four (4) weeks Laboratory and x-ray services Within three (3) weeks for routine appointments and forty-eight (48) hours (or as clinically indicated) for urgent care. Family Planning Services Within seven (7) calendar days. High volume specialty care - high volume Within thirty (30) calendar days of referral. specialists include cardiologists, neurologists, hematologists/oncologists, OB/GYNs, and orthopedic physicians.

16 PCP- Type of appointment Scheduling time-frame Maternity Care Within fourteen (14) calendar days of request during the first trimester, within seven (7) calendar days of request during the second trimester, and within three (3) calendar days of request during the third trimester. For high-risk pregnancies, the member must be seen within three (3) calendar days of identification of high risk by the health plan or maternity care provider or immediately if an emergency exists.

Behavioral Health Services scheduling Behavioral health service Appointment time Explanation Non-Life-Threatening Within six (6) hours of Emergency services available at Emergency presentation or request all times Urgent Care (may be directed Within forty-eight (48) Appointments shall be arranged by PCP or Nebraska Total hours of presentation or within forty-eight (48) hours of Care) request. request Non-Urgent, routine Within fourteen (14) days NA of request Follow-up to ED visits Within seven (7) days NA Follow-up to hospitalization Within seven (7) days NA Phone Access Twenty-four (24) hour Call must be promptly processed access through call and referred to the appropriate sharing or answering person for follow up. service.

Office wait times Primary Care Provider, Behavioral Health Office wait times Provider, Maternity, and Specialist Walk-in Within two (2) hours or schedule an appointment within the standards of appointment availability Previously scheduled appointment Within 45 minutes of appointment Life-threatening emergency Immediate

17 Access standards Nebraska Total Care offers a comprehensive network of PCPs, Specialist Physicians, Hospitals, Behavioral Health Care Providers, Diagnostic and Ancillary Services Providers to ensure every member has access to covered services. Below are the travel distance and access standards that Nebraska Total Care utilizes to monitor its network adequacy:

Provider Type Minimum Number Distance PCP Urban Counties Two (2) PCPs Within thirty (30) miles of member’s personal residence PCP Rural Counties One (1) PCP Within forty-five (45) miles of member’s personal residence PCP Frontier Counties One (1) PCP Within sixty (60) miles of member’s personal residence High Volume Specialists. One (1) high volume Within Ninety (90) miles of High volume specialties specialist member’s personal residence include cardiology, neurology, hematology/oncology, obstetrics/gynecology, and orthopedics Behavioral health inpatient Sufficient locations to allow and residential service members to travel by car or providers other transit provider and return home within a single day in rural and frontier areas Behavioral Health OP- Adequate choice Within thirty (30) miles of Urban Counties member’s personal residence Behavioral Health OP- Rural Two (2) providers Within thirty (30) miles of Counties member’s personal residence Behavioral Health OP- Two (2) providers Within forty-five (45) miles of Frontier Counties member’s personal residence

MINIMUM PCP HOURS PCPs who have a one-physician practice must have office hours of at least 20 hours per week. Practices with two or more physicians must have office hours of at least 30 hours per week.

COVERING PROVIDERS PCPs and specialty physicians must arrange for coverage with another provider during scheduled or unscheduled time off and preferably with another Nebraska Total Care network provider. In the event of unscheduled time off, please notify Provider Services department of coverage arrangements as soon as possible. The covering physician is compensated in accordance with the fee schedule in their agreement, and, if not a Nebraska Total Care network provider, he/she should be paid as a nonparticipating provider.

18 TELEPHONE ARRANGEMENTS PCPs and Specialists must: • Answer the member’s telephone inquiries on a timely basis • Prioritize appointments • Schedule a series of appointments and follow-up appointments as needed by a member • Identify and, when possible, reschedule broken and no-show appointments • Identify special member needs while scheduling an appointment (e.g., and interpretive linguistic needs, non-compliant individuals, or those people with cognitive impairments) • Adhere to the following response time for telephone call-back waiting times:

o After-hours telephone care for non-emergent, symptomatic issues within 30 minutes o Same day for non-symptomatic concerns • Schedule continuous availability and accessibility of professional, allied, and supportive personnel to provide covered services within normal working hours. Protocols shall be in place to provide coverage in the event of a provider’s absence • After-hour calls should be documented in a written format in either an after-hour call log or some other method, and then transferred to the member’s medical record NOTE: If after-hour urgent care or emergent care is needed, the PCP or his/her designee should contact the urgent care center or emergency department in order to notify the facility. Notification is not required prior to member receiving urgent or emergent care. Nebraska Total Care will monitor appointment and after-hours availability on an on-going basis through its Quality Assurance and Performance Improvement Committee (QAPIC).

24-HOUR ACCESS Nebraska Total Care PCPs are required to maintain sufficient access to facilities and personnel to provide covered physician services and shall ensure that such services are accessible to members as needed 24 hours a day, 365 days a year as follows: • A provider’s office phone must be answered during normal business hours • During after-hours, a provider must have arrangements for one of the following:

o Access to a covering physician, o An answering service, o Triage service, or o A voice message that provides a second phone number that is answered. o Any recorded message must be provided in English and Spanish, if the provider’s practice includes a high population of Spanish speaking members. Examples of Unacceptable After-Hours Coverage include, but are not limited to: • The Provider’s office telephone number is only answered during office hours; • The Provider’s office telephone is answered after-hours by a recording that tells patients to leave a message; • The Provider’s office telephone is answered after-hours by a recording that directs patients to go to an Emergency Room for any services needed; and • A Clinician returning after-hours calls outside 30 minutes.

19 The selected method of 24-hour coverage chosen by the provider must connect the caller to someone who can render a clinical decision or reach the PCP for a clinical decision. Whenever possible, the PCP, or covering medical professional must return the call within 30 minutes of the initial contact. After-hours coverage must be accessible using the medical office’s daytime telephone number. Nebraska Total Care will monitor providers’ offices After-Hour Coverage through surveys and through mystery shopper calls conducted by Nebraska Total Care Provider Network staff.

HOSPITAL RESPONSIBILITIES Nebraska Total Care utilizes a network of hospitals to provide services to Nebraska Total Care members. Hospital services providers must be qualified to provide services under the Medicaid program. All services must be provided in accordance with applicable state and federal laws and regulations and adhere to the requirements set forth in the Heritage Health Agreement with Nebraska DHHS. Hospitals must: • Notify the PCP immediately or no later than the close of the next business day after the member’s emergency room visit • Obtain authorizations for all inpatient and selected outpatient services as listed on the current prior authorization list, except for emergency stabilization services • Notify Nebraska Total Care Medical Management department by sending an electronic file of the ER admission by the next business day. The electronic file should include the member’s name, Medicaid ID, presenting symptoms/diagnosis, DOS, and member’s phone number • Notify Nebraska Total Care Medical Management department of all admission within one business day • Report births of newborns to Nebraska Total Care within 24 hours of birth for enrolled members

ADVANCE DIRECTIVES Nebraska Total Care is committed to ensure that its members are aware of and are able to avail themselves of their rights to execute advance directives. Nebraska Total Care is equally committed to ensuring that its providers and staff are aware of and comply with their responsibilities under federal and state law regarding advance directives. PCPs and providers delivering care to Nebraska Total Care members must ensure adult members 19 years of age and older receive information on advance directives and are informed of their right to execute advance directives. Providers must document such information in the permanent medical record. Nebraska Total Care recommends to its PCPs and physicians that: • The first point of contact for the member in the PCP’s office should ask if the member has executed an advance directive and the member’s response should be documented in the medical record. • If the member has executed an advance directive, the first point of contact should ask the member to bring a copy of the advance directive to the PCP’s office and document this request in the member’s medical record.

20 • An advance directive should be a part of the member’s medical record and include mental health directives. If an advance directive exists, the physician should discuss potential medical emergencies with the member and/or designated family member/significant other (if named in the advance directive and if available) and with the referring physician, if applicable. Any such discussion should be documented in the medical record.

VOLUNTARILY LEAVING THE NETWORK Providers must give Nebraska Total Care notice of voluntary termination following the terms of their participating agreement with our health plan. In order for a termination to be considered valid, providers are required to send termination notices via certified mail (return receipt requested) or overnight courier. In addition, providers must supply copies of medical records to the member’s new provider upon request and facilitate the member’s transfer of care at no charge to Nebraska Total Care or the member. Nebraska Total Care will notify affected members in writing of a provider’s termination, within 15 calendar days of the receipt of the termination notice from the provider, provided that such notice from the provider was timely. Providers must continue to render covered services to members who are existing patients at the time of termination until the later of 60 days or until Nebraska Total Care can arrange for appropriate healthcare for the member with a participating provider.

21 CULTURAL COMPETENCY Cultural competency within Nebraska Total Care is defined as the willingness and ability of a system to value the importance of culture in the delivery of services to all segments of the population. It is the use of a systems perspective which values differences and is responsive to diversity at all levels in an organization. Cultural Competency is developmental, community focused, and family oriented. In particular, it is the promotion of quality services to understand racial/ethnic groups through the valuing of differences and integration of cultural attitudes, beliefs and practices into diagnostic and treatment methods and throughout the system to support the delivery of culturally relevant and competent care. It is also the development and continued promotion of skills and practices important in clinical practice, cross-cultural interactions and systems practices among providers and staff to ensure that services are delivered in a culturally competent manner. Nebraska Total Care is committed to the development, strengthening, and sustaining of healthy provider/member relationships. Members are entitled to dignified, appropriate, and quality care. When healthcare services are delivered without regard for cultural differences, members are at risk for sub-optimal care. Members may be unable or unwilling to communicate their healthcare needs in an insensitive environment, reducing effectiveness of the entire healthcare process. Providers should note that the experience of a member begins at the front door. Failure to use culturally competent and linguistically competent practices could result in the following: • Feelings of being insulted or treated rudely • Reluctance and fear of making future contact with the office • Confusion and misunderstanding • Treatment Non-compliance • Feelings of being uncared for, looked down on, and devalued • Parents resisting to seek help for their children • Unfilled prescriptions • Missed appointments • Misdiagnosis due to lack of information sharing • Wasted time • Increased grievances or complaints Nebraska Total Care as part of its credentialing will evaluate the cultural competency level of its network providers and provide access to training and tool kits to assist providers in developing culturally competent and culturally proficient practices. Network providers must ensure: • Members understand that they have access to qualified medical interpreters, signers, and TDD/TTY services to facilitate communication without cost to them • Medical care is provided with consideration of the member’s race/ethnicity and language and its impact/influence on the member’s health or illness • Office staff that routinely interact with members have access to and participate in cultural competency training and development • Office staff responsible for data collection make reasonable attempts to collect race- and language-specific member information. Staff will also explain race/ethnicity categories to a member so that the member is able to identify the race/ethnicity of themselves and their children

22 • Treatment plans are developed with consideration of the member’s race, country of origin, native language, social class, religion, mental or physical abilities, heritage, acculturation, age, gender, sexual orientation, gender identity, and other characteristics that may influence the member’s perspective on healthcare Office sites have posted and printed materials in English and Spanish, and other prevalent non- English languages required by the Nebraska Department of Health and Human Services (DHHS). The road to developing a culturally competent practice begins with the recognition and acceptance of the value of meeting the needs of your patients. Nebraska Total Care is committed to helping you reach this goal. A tribal consultant will be a resource at the plan to help enhance the cultural competency of providers. Take into consideration the following as you provide care to the Nebraska Total Care members: • What are your own cultural values and identity? • How do or can cultural differences impact your relationship with your patients? • How much do you know about your patient’s culture and language? • Does your understanding of culture take into consideration values, communication styles, spirituality, language ability, literacy, and family definitions? • Do you embrace differences as allies in your patients’ healing process? The U.S. Department of Health and Human Services' Office of Minority Health has published a suite of online educational programs to Advance Health Equity at Every Point of Contact through development and promotion of culturally and linguistically appropriate services. Visit Think Cultural Health at thinkculturalhealth.hhs.gov to access these free online resources.

23 BENEFIT EXPLANATIONS AND LIMITATIONS Nebraska Total Care network providers supply a variety of medical and behavioral health benefits and services, some of which are itemized on the following pages. For specific information not covered in this provider manual, please contact Provider Services at 1-844-385- 2192, Nebraska Relay Service 711. A Provider Service Representative will be happy to assist you. Nebraska Total Care covers, at a minimum, those core benefits and services specified in our Agreement with Nebraska DHHS and defined in the, administrative rules, and Department policies and procedure handbook. Nebraska Total Care claims payment will preclude payment to providers for provider- preventable conditions (PPCs) in compliance with 42 CFR 447.26(b). PPCs, including health care acquired conditions (HACs), are those conditions that occur in inpatient hospital settings. Nebraska Total Care will reference CMS– 2015 Health Care Acquired Conditions for a listing of HACs that apply to this provision, with the exception of deep vein thrombosis/pulmonary embolism following total knee replacement or hip replacement in pediatric and obstetric patients.

COVERED SERVICES All services are subject to benefit coverage, limitations, and exclusions as described in applicable plan coverage guidelines. Use the Pre-Auth Check Tool at NebraskaTotalCare.com to quickly determine if a specific service requires authorization. All Out of Network (Non-Par) services require prior authorization, excluding family planning, emergency room, and tabletop x-ray.

Service Comments Inpatient hospital services Including transitional hospital services and transplant services Outpatient hospital services NA Ambulatory surgical center (ASC) NA services. Physician services Including services provided by nurse practitioners, certified nurse Midwives, physician assistants, - administered injections/medications, and anesthesia services including those provided by a certified registered nurse anesthetist. Federally-qualified health centers NA (FQHCs) services Rural health (RHCs) services NA Indian Health Service (IHS) NA Laboratory services Clinical and anatomical Radiology services NA

24 Service Comments Health Check (EPSDT) services NA Home health services NA Private duty nursing services NA Therapy services Including physical, occupational, and speech pathology and audiology. Durable medical equipment and Including hearing aids, orthotics, prosthetics, and medical supplies nutritional supplements Podiatry services NA Chiropractic services NA Vision services NA Free standing birth center services NA services Except when provided in a nursing facility. Skilled/rehabilitative and transitional NA nursing facility services Ambulance services NA Non-emergency ambulance NA transportation Transplant services NA Pharmacy services NA

Behavioral Health Limitations Comments Services Crisis stabilization NA Includes treatment crisis intervention services Inpatient psychiatric NA Acute and sub-acute hospital Psychiatric residential Covered for age 19 NA treatment facility and under Outpatient assessment Covered for • Partial hospitalization and treatment individuals age 20 • Day treatment and under • Intensive outpatient • Medication management • Outpatient therapy (individual, family, or group) • Injectable psychotropic medications • Substance use disorder treatment • Psychological evaluation and testing • Initial diagnostic interviews • Sex offender risk assessment • Community treatment aide (CTA) services (continued on next page)

25 Behavioral Health Limitations Comments Services Outpatient assessment Covered for • Partial hospitalization and treatment (continued) individuals age 20 • Day treatment and under • Intensive outpatient • Medication management • Outpatient therapy (individual, family, or group) • Injectable psychotropic medications • Substance use disorder treatment • Psychological evaluation and testing • Initial diagnostic interviews • Sex offender risk assessment • Community treatment aide (CTA) services Outpatient assessment Covered for adults • Ambulatory detoxification and treatment age 21 and over. • Day treatment • Electroconvulsive therapy • In-home psychiatric nursing • Initial diagnostic interviews • Injectable psychotropic medications • Intensive outpatient • Medication management • Outpatient therapy (individual, family, or group) • Peer Support • Partial hospitalization • Psychological evaluation and testing • Social detoxification • Substance use disorder treatment Rehabilitation services Covered for • Day treatment/intensive outpatient individuals age 20 • CTA services and under. • Professional resource family care • Therapeutic group home Rehabilitation services Covered for • Dual-disorder residential individuals age 21 • Intermediate residential (SUD) and over • Short-term residential • Halfway house • Therapeutic community (SUD only) • Community support • Psychiatric residential rehabilitation • Secure residential rehabilitation • Assertive community treatment (ACT) and Alternative (Alt) ACT • Community support • Day rehabilitation

26 SPECIAL SERVICES TO ASSIST MEMBERS

Non-Emergent Medical Transportation (NEMT) Nebraska Total Care works with MTM, Inc. to provide non-emergent medical transportation for eligible members to their medical and behavioral health appointments. • Visit NebraskaTotalCare.com, under our ‘For Providers’ section, to access our NEMT provider webpage that contains key information on doing business with MTM, claims submissions, tracking ride assignments, FAQ and using the MTM provider portal. Members are to schedule rides at least three working days before an appointment and can schedule a ride up to 30 days before an appointment. In some situations, a ride can be scheduled more than 30 days before an appointment. Sometimes urgent medical trips can be requested by members with less than 3 days’ notice. In those instances MTM may check with the provider to confirm the appointment is urgent. NEMT can go to providers within 20 miles or in situations where there is not a provider within 20 miles, they can take you to the closest provider. When members choose a provider farther away transportation services may not be available. MTM also can offer other transportation options. Those could be: • Public transportation • Commercial vehicle • Wheelchair lift equipped vehicle • Escort • Commercial air, bus and train Providers can file a transportation complaint if you: • Are not happy with MTM’s services or processes re not happy about any other part of working with MTM You can make your complaint to Nebraska Total Care following the Provider grievance process outlined in this manual.

Women’s Health Care Nebraska Total Care will provide direct access to a health specialist in network for core benefits and services necessary to provide women routine and preventive health care services in addition to the member’s PCP if the provider is not a women’s health specialist. Members are allowed to utilize their own PCP or any family planning service provider for family planning services without the need for a referral or a prior authorization. In addition, members will have the freedom to receive family planning services and related supplies from an out of network provider without any restrictions. Family planning services include examinations, assessments, traditional contraceptive services, preconception and inter- conception care services. Nebraska Total Care will make every effort to contract with all local family planning clinic and providers and will ensure reimbursement whether the provider is in or out of network.

27 VALUE ADDED SERVICES

Adult Vaccines Nebraska Total Care will offer vaccines administered at a participating pharmacy to members 21 years of age and over based on medical necessity. Covered vaccines include: • Pneumonia Vaccine • Influenza Vaccine • Shingles Vaccine • Meningitis Vaccine

Second Epipen and or Nebulizer for School Nebraska Total Care provides members who have severe allergies or asthma access to a second Epipen and/or a nebulizer to eliminate the need for children to have to remember to bring the device back and forth from home while being able to address acute episodes, should they occur while the child is in school. Available to member ages 5-18 who have severe allergies or asthma and are enrolled in school.

Enhanced Transportation Benefit Nebraska Total Care has enhanced transportation benefits through MTM to certain non-covered health related activities such as: • Alcoholics Anonymous or Narcotics Anonymous meetings • Approved exercise and nutrition classes • Birthing and parenting classes, and Start Smart Baby Showers • Weight Watchers meetings • WIC (Women, Infant and Children) appointments

Over the Counter Pharmacy Benefit As a commitment to our members overall health and well-being, Nebraska Total Care offers a benefit of $30 for Nebraska Total Care members per quarter in commonly-used over-the- counter (OTC) items through our affiliate Envolve Pharmacy Solutions and its mail order program, Homescripts. Members are able to select from a catalog of items supplied by Nebraska Total Care up to the program specific limit per quarter per household. Items on the list include, but are not limited to: pain relievers, antacids, vitamins and minerals, and cough/cold/allergy . Orders will be placed with Homescripts by calling a toll-free number or ordering via their website.

Waive Co-pays Nebraska Total Care is waiving co-pays for medical, generic pharmacy, and behavioral health services, as we have found that waiving co-pays helps reduce barriers to accessing care and encourages the utilization of care in the appropriate setting.

28 Sports/Camp Physical To promote healthier lifestyles and to encourage members to exercise more regularly and participate in regular team and independent fitness activities, Nebraska Total Care reimburses providers for Sports Physicals for members ages 4 to 18. It is recognized that Sports Physicals are required by junior and high school athletic programs and some youth sports leagues, as well as camps, to check both medical history and to conduct a physical exam. These exams are important to ensure that children are in good physical condition and that it is safe for them to participate in a sport that requires physical exertion and provides an opportunity to limit risk or injury. The Sports/Camp Physical must be rendered by a participating Nebraska Total Care provider.

GED Testing Materials Nebraska Total Care wants to provide our members with opportunities to further their education and assist them in taking the necessary steps to reduce the need for reliance on programs such as Medicaid. For some of our members, that step includes completing their high school education. Nebraska Total Care provides vouchers to eligible members to be used toward the purchase of official GED testing practice materials to prepare them for the official GED test.

Free Membership to Boys and Girls Club To assist Nebraska Total Care members in developing social and leadership skills, Nebraska Total Care sponsors the membership fee to the local Boys and Girls Club. According to their website, the Omaha Boys and Girls Club aims to minimize violence, peer pressure, and other risky activities by engaging young people in activities with positive adult role models and peers, enabling them to learn powerful life skills. This benefit will be available to all Nebraska Total Care members aged 6-18 years old. The Boys and Girls Club will bill Nebraska Total Care for membership fees.

Weight Watchers Nebraska Total Care has partnered with Weight Watchers to provide eligible members free membership for online Weight Watchers participation for members who meet BMI criteria. Members receive vouchers for registration for 14 weeks of online tools. They have the option to receive additional vouchers if criteria is met.

Trial Membership to YMCA Free 90 day trial fitness memberships to the YMCA for individuals and families who are Nebraska Total Care members.

Community Gardens Nebraska Total Care will pay for one community garden plot per household, to established community garden organizations.

ConnectionsPlus® Cell Phone Nebraska Total Care has partnered with a certified Nebraska Telecommunications Assistance Program (NTAP) select carrier to refer qualifying individuals to the Program as well as enhancing the service by providing unlimited texting, discount on additional minutes above the 250 minutes allotted with the phone and unlimited calls with Nebraska Total Care health plan staff. In addition, for those members that are in Care Management and stratified as high risk and/or unable to qualify for the Nebraska Program, Nebraska Total Care will implement our ConnectionsPlus® free cell phone program. Even for members who do qualify for the Nebraska Telecommunications Assistance Program, the minimum allotted minutes can present as a barrier to successful and regular care management; decreases member likelihood of

29 participating in a health program that requires usage of minutes; and is not enough minutes to support the extent of care coordination and social support services some members require. Nebraska Total Care’s free ConnectionsPlus® phones are available to high-risk members who would benefit from unlimited talk and text and we are also able to offer a smart phone and data plan for select members with a specific chronic condition or disease where an app exists to encourage healthy lifestyles and help manage their condition. The objective of the program is to reduce preventable adverse events such as inappropriate ER use or hospital admissions through improved access to health care information and treating providers. Members are educated on observing their health status and calling promptly for advice and support rather than waiting until the next appointment. The cell phones are also used so that Care Managers can send the member a text message with health information targeted to the individual member's condition.

Screening, Brief Intervention & Referral to Treatment (SBIRT) SBIRT is an evidence-based intervention aimed at improving the overall health and well-being of individuals who are using alcohol and illicit substances in a risky and harmful manner, and increasing access to evaluation and treatment for individuals with a substance use disorder. Nebraska Total Care covers the initial SBIRT service code, in addition to training providers on valid screening tools to assist providers in determining the appropriate level of intervention or referral for services. In order for a provider to provide this service, the provider must participate in the Nebraska Total Care SBIRT training program or a SAMHSA endorsed SBIRT training program.

Start Smart for Your Baby® Prenatal and Postpartum Incentives Start Smart for Your Baby® (Start Smart) is our prenatal/postpartum support program that incorporates care management, care coordination, and disease management in an effort to improve the health of pregnant mothers and birth outcomes. To further incentivize members to attend prenatal and postpartum appointments, Nebraska Total Care provides the following additional incentives: • Notification of Pregnancy (NOP) and Postpartum Visit

o If Nebraska Total Care has received a NOP form on a member and the member completes the postpartum visit within four to six weeks of delivery, the member can earn $10 on the member’s Healthy Rewards. Member will use a voucher form which will need be signed by the Provider’s office verifying the visit and submit to the health plan. • Start Smart for Your Baby® Texting

o The texting program provides messages related to pregnancy, postpartum and newborn care reminders. Members can receive $ per month for responding to monthly texting messages. • Breast Pumps for all nursing mothers who have a need. One breast pump is available every two years. • Members who have a prescription for a breast pump will be offered one electronic breast pump (one per member per delivery). Breast pumps maybe be ordered between the 37th week of pregnancy until 45 days after delivery. Pumps will be provided by an in network DME provider. Hospital grade pumps are available for rent with a prior authorization. Please contact customer service at 1-844-385-2192, Nebraska Relay Service 711 for assistance.

30 Healthy Rewards Nebraska Total Care rewards members’ healthy choices through our Healthy Rewards program. This card can be used to purchase items and products to drive healthy behaviors and healthy outcomes. Members can earn dollar rewards by staying up-to-date on preventive care, including well-child visits and immunizations. Members have the ability to buy things like fresh foods and groceries, frozen foods, baby items and clothing (diapers, formula, baby foods, etc.), as well as certain over-the-counter drugs (allergy, cold meds, etc.) and other personal care items (deodorant, soap, shampoo, etc.). Members can use their Healthy Rewards card at a select number of retailers including Wal-Mart. The rewards card may also be used to help pay for utilities, transportation, telecommunications, childcare services, education and rent at eligible retailers. Members can visit the secure member portal for the most up-to-date listing of approved items and retailers.

PAL (Psychiatric Access Line) Nebraska Total Care will provide a 24/7 Psychiatric Access Line to support primary care providers in appropriate BH prescribing, screening, identification and referral. The Psychiatric Assistance Line (PAL) is a telephone-based consultation system for primary care providers. PAL is staffed by psychiatrists and has a master’s-level social workers who can assist with support on behavioral prescribing, screening, identification and referral. PAL is available to primary care doctors, nurse practitioners and physician assistants throughout the states of Nebraska. PAL provides rapid consultation responses for any type of mental health issue that arises via a toll free number. To access the PAL line, please call Nebraska Total Care at 1-844- 385-2192, Nebraska Relay Service 711. Select “3” for Providers, then “5” for Mental Health Services. Ask for the PAL Line.

31 NETWORK DEVELOPMENT AND MAINTENANCE Nebraska Total Care maintains a network of qualified providers in sufficient numbers and locations that is adequate and reasonable in number, in specialty type, and in geographic distribution to meet the medical needs of its members, both adults and children, without excessive travel requirements, and that is in compliance with DHHS’ access and availability requirements. Nebraska Total Care offers a network of primary care providers to ensure every member has access to a Medical Home within the required travel distance standards. In addition, Nebraska Total Care will have available, at a minimum, the following providers. Specialists: • Applied Behavior Analyst • Allergist • Anesthesiologist • Behavioral Health Counselors • Cardiologist • Cardiovascular Surgeon • Dermatologist • Gastroenterologist • General Surgeon • Neurologist • OB/GYN • Oncologist • Ophthalmologist • Optometrist • Orthopedic Surgeon • Psychiatrist • Psychologist • Pulmonologist • Radiologist • Urologist • Facilities: • Hospitals • Inpatient psychiatric hospitals • Laboratory services • End stage renal disease treatment and transplant centers • Outpatient mental health centers/Community mental health centers • Substance use programs • Independent radiology centers

32 In the event Nebraska Total Care’s network is unable to provide medically necessary services required under the contract, Nebraska Total Care shall ensure timely and adequate coverage of these services through an out of network provider until a network provider is contracted and will ensure coordination with respect to authorization and payment issues in these circumstances. For assistance in making a referral to a specialist or subspecialties for a Nebraska Total Care member, please contact our Medical Management team at 1-844-385-2192, Nebraska Relay Service 711 and we will identify a provider to make the necessary referral.

NON-DISCRIMINATION We do not limit the participation of any provider or facility in the network, and/or otherwise discriminate against any provider or facility based solely on any characteristic protected under state or federal discriminate laws. Furthermore, we do not and have never had a policy of terminating any provider who: • advocated on behalf of a member • filed a complaint against us • appealed a decision of ours

TERTIARY CARE Nebraska Total Care offers a network of tertiary care inclusive of trauma centers, burn centers, level III (high risk) nurseries, rehabilitation facilities and medical sub-specialists available 24- hours per day in the geographical service area. In the event Nebraska Total Care’s network is unable to provide the necessary tertiary care services required, Nebraska Total Care shall ensure timely and adequate coverage of these services through an out of network provider until a network provider is contracted and will ensure coordination with respect to authorization and payment issues in these circumstances.

33 MEDICAL MANAGEMENT Nebraska Total Care Medical Management department hours of operation are Monday through Friday from 8 a.m. to 5 p.m., CST (excluding holidays). After normal business hours, our 24/7 nurse advice hotline staff is available to answer questions about prior authorization. Medical Management services include the areas of utilization management, care management, population management, and quality review. The department clinical services are overseen by the Nebraska Total Care medical director (“Medical Director”). The Vice President (VP) of Medical Management has responsibility for direct supervision and operation of the department. To reach the Medical Director or VP of Medical Management contact Medical Management at 1- 844-385-2192, Nebraska Relay Service 711. Utilization management and care management policies are available to be furnished to providers upon their request.

INTEGRATED CARE The Integrated Behavioral Health approach utilizes a holistic approach, focusing on the whole person, and includes integrating needed covered, carved out, and community-based services in its approach to care. We use a multi-disciplinary Integrated Care Team to offer and coordinate integrated care. Our staff coordinates care with all necessary members of the designated care team, including the member’s primary and specialty providers, other care team members, and those identified as having a significant role in the member’s life, as appropriate. Our overarching goal is to help each and every Nebraska Total Care member achieve the highest possible levels of wellness, functioning, and quality of life, while demonstrating positive clinical results. Integrated care is an integral part of the range of services that we provide to all members. Through this program, we continually strive to achieve optimal health status through member engagement and behavior change motivation. Integrated care does this through a comprehensive approach that includes: • Strong support for the integration of both physical and behavioral health services • Assisting members in achieving optimum health, functional capability, and quality of life • Empowering members through assistance with referrals and access to available benefits and resources • Working collaboratively with members, family and significant others, providers, and community organizations to assist members using a holistic approach to care • Maximizing benefits and resources through oversight and cost-effective utilization management • Rapid and thorough identification and assessment of program participants, especially members with special health care needs • A team approach that includes staff with expertise and skills that span departments and services • Information technologies that support care coordination within plan staff and among a member’s providers and • Multifaceted approaches to engage members in self-care and improve outcomes • Multiple, continuous quality improvement processes that assess the effectiveness of integrated care, and identify areas for enhancement to fully meet member priorities. • Assessment of member’s risk factors and needs

34 • Contact with high-risk members discharging from hospitals to ensure appropriate discharge appointments are arranged and members understand treatment recommendations • Active coordination of care linking members to behavioral health practitioners and as needed medical services; including linkage with a physical health Care Manager for members with coexisting behavioral and physical health conditions; and residential, social and other support services where needed • Development of a care management plan of care • Referrals and assistance to community resources and/or behavioral health practitioners • For members not hospitalized but in need of assistance with overcoming barriers to obtaining behavioral health services or compliance with treatment, we offer Care Coordination. The model emphasizes direct member contact, such as telephonic out-reach and educational materials. Additionally some specific programs may provide face-to-face education, because it more effectively engages members, allows staff to provide information that can address member questions in real time and better meet member needs. Participating members also receive written materials, preventive care and screening reminders, invitations to community events, and can call anytime regarding health care and psychosocial questions or needs. Recognizing that each member’s clinical condition and psychosocial situation is unique, Integrated Behavioral Health interventions and information meet each member’s unique circumstance, and will vary from one member to another, including those with the same diagnosis.

COMPLEX CARE MANAGEMENT PROGRAM Nebraska Total Care’s care management model is designed to help your Nebraska Total Care members obtain needed services, whether they are covered within the Nebraska Total Care array of covered services, from community resources, or from other non-covered venues. Our model will support our provider network whether you work in an individual practice or large multi-specialty group setting. The program is based upon a coordinated care model that uses a multi-disciplinary care management team in recognition that a holistic approach yields better outcomes. The goal of our program is to help members achieve the highest possible levels of wellness, functioning, and quality of life, while decreasing the need for disruption at the PCP or specialist office with administrative work. The program includes a systematic approach for early identification of eligible members, needs assessment, and development and implementation of an individualized care plan that includes member/family education and actively links the member to providers and support services as well as outcome monitoring and reporting back to the PCP. It is the PCP’s responsibility to contact Care management for updates. We will coordinate access to services not included in core benefit package such as, vision and pharmacy services. Our program incorporates clinical determinations of need, functional status, and barriers to care such as lack of supports, impaired cognitive abilities and transportation needs.

35 A care management team is available to help all providers manage their Nebraska Total Care members. Listed below are programs and components of special services that are available and can be accessed through the care management team. We look forward to hearing from you about any Nebraska Total Care members that you think can benefit from the addition of a Nebraska Total Care’s care management team member. To contact a care manager call 1-844-385-2192, Nebraska Relay Service 711.

High Risk Pregnancy Program The Maternity Team will implement our Start Smart for Your Baby® Program (Start Smart), which incorporates care management, care coordination, and disease management with the aim of decreasing preterm delivery and improving the health of moms and their babies. Start Smart is a unique perinatal program that follows women for up to one year after delivery and includes neonates and qualified children up to one year of age. The program goals are improving maternal and child health outcomes by providing pregnancy and parenting education to all pregnant members and providing care management to high and moderate risk members through the postpartum period. A nurse care manager with obstetrical experience will serve as lead care manager for members at high risk of early delivery or who experience complications from pregnancy. An experienced neonatal nurse will be the lead care manager for newborns being discharged from the NICU and will follow them through the first year of life (if they remain eligible with the Plan) as needed based on their specific condition or diagnosis. The Maternity team has physician oversight advising the team on overcoming obstacles, helping identify high risk members, and recommending interventions. These physicians will provide input to Nebraska Total Care Medical Director on obstetrical care standards and use of newer preventive treatments such as 17 alpha-hydroxyprogesterone caproate (17-P). Nebraska Total Care offers a premature delivery prevention program by supporting the use of 17-P. There is no prior authorization necessary for the use of McKena 17-P product. When a physician determines that a member is a candidate for 17-P, which use has shown a substantial reduction in the rate of preterm delivery, he/she will write a prescription for 17-P. This prescription is sent to the health plan care manager who will check for eligibility. The care manager will assist the member with finding a pharmacy to fill the prescription as well as coordinate transportation to and from the physician’s office. The nurse manager will contact the member and do an assessment regarding compliance. The nurse will remain in contact with the member and the prescribing physician during the entire treatment period. The Maternity Team works in collaboration with local PCP’s, FQHC’s, Health Homes and local Health Departments to support this program with the goal of improved maternity/neonate care in Nebraska. Contact Nebraska Total Care’s Care Management Department for enrollment in the obstetrical program. Medically Complex Members Members must be assessed for health conditions to determine if they qualify for designation as medically complex based upon their physical health, behavioral health or social determinant of health (SDoH) needs. All members identified as medically complex will be offered care and case management services to support their integrated health and SDoH needs. Multifaceted approaches are utilized to assess the member’s needs.

1. Care and Case Management planning includes, but is not limited to the following resources:

36 • MLTC’s Homelessness Identification form • MLTC’s Medically Complex Self-Identification form provided to the member in the member benefit packet • MCO specific health risk assessment • Medical records • Predictive analytic tools which are technology-based patient stratification tools that help identify high-risk and rising-risk members • Historical claims data • Provider referrals • State-wide HIE • State-registries • PDMP • Health Risk Screening (HRS)

2. Identification of members who are appropriate for Case Management include those with or who are: • A disabling mental disorder; • A chronic substance abuse disorder; • A physical, intellectual, or developmental disability with functional impairment that significantly impairs the individual from performing one or more activities of daily living each time the activity occurs, see 471 NAC 12 for the definition of activities of daily living for adults; • A disability determination based on Social Security or SRT criteria; • DHHS Medically Complex ICD-10 Diagnosis code listing • Complex medical condition(s) • Currently homeless or at risk for homelessness; • Foster care children and adolescents aging out of the foster care system • Dual eligibles • Transitioning from incarceration into the community • Special Needs adolescents who will be aging out and no longer eligible for EPSDT services

Standardized forms are available and supplied to members to support Medically Complex self- identification and assessment:

1. Medically Complex Self-Identification form: a. The form may be completed by the member, their caregiver, family member or friend, authorized representative, or a b. This form is included in the welcome packet provided to the member by Nebraska Total Care c. Self-Identification forms received by Nebraska Total Care are processed and the member is referred to care and/or case management

2. Homelessness Identification form: a. This form is used to identify members who are currently experiencing homelessness or are at risk for becoming homeless. b. The form can be completed by the member, their caregiver, family member or friend, authorized representative, a health care provider or provider of homeless services.

37 c. This form is included in the welcome packet provided to the member by Nebraska Total Care d. Homelessness forms received by Nebraska Total Care are processed and the member is referred to care and/or case management Complex Teams These teams will be led by licensed registered nurses, or a licensed behavioral health clinician, with either adult or pediatric expertise as applicable. For both adult and pediatric teams, staff will be familiar with evidence-based resources and best practice standards and experience with the population, the barriers and obstacles they face, and socioeconomic impacts on their ability to access services. The complex teams will manage care for members whose needs are primarily functional as well as those with such complex conditions as HIV, diabetes, CHF, and renal dialysis. Foster care members and children with special health care needs are at special risk and are also eligible for enrollment in care management.

Community Health Workers Community Health Workers for Nebraska Total Care conduct outreach designed to provide education to our members on how to access healthcare and develop healthy lifestyles in a setting where they feel most comfortable. The program components are integrated as a part of our care management program in order to link Nebraska Total Care and the community served. The program recruits staff from the communities serviced to establish a grassroots support and awareness of Nebraska Total Care within the community. The program has various components that can be provided depending on the need of the member. Members can be referred to Community Health Workers through numerous sources. Members who call the Nebraska Total Care Customer Service department may be referred for more personalized discussion on the topic they are inquiring about. Care managers may identify members who would benefit from a Community Health Worker and complete a referral request. Providers may request Community Health Worker referrals directly to a team representative or their assigned Care Manager. Community groups may request that a Community Health Worker come to their facility to present to groups they have established or at special events or gatherings. Various components of the program are described below. Community Connections: Community Health Workers are available to present to group setting during events initiated by state entities, community groups, clinics, or any other approved setting. This form of community connections is extremely useful in rural areas where home visits may be the only mode of communication. Presentations may typically include what Medicaid coordinated care is all about, overview of services offered by Nebraska Total Care, how to use the health plan and access services, the importance of obtaining primary preventive care, and other valuable information related to obtaining services from providers and Nebraska Total Care. Home Connections: Community Health Workers are available on a full-time basis whenever a need or request from a care manager, member or provider. All home visits are unscheduled due to the fact that the care manager has been unable to make contact with the member. Some home visits can be scheduled when it involves them delivering a cell phone to the member in order to have easier access to the member. Topics covered during a home visit include overview of covered benefits, how to schedule an appointment with the PCP, the importance of preventive health care, appropriate use of preventive, urgent and emergency care services, obtaining medically necessary transportation, and how to contact the health plan for assistance. Phone Connections: Community Health Workers may contact new members or members in need of more personalized information to review the health plan material over the telephone. All the previous topics may be covered and any additional questions answered.

38 ConnectionsPlus® Cell Phone: Community Health Workers work together with the high risk OB team or care management team for high risk members who do not have safe, reliable phone access. When a member qualifies, a Connections Representative visits the member’s home and gives them a free, pre-programmed cell phone with limited use. Members may use this cell phone to call the health plan care manager, PCP, specialty physician, 24/7 nurse advice hotline, 911, or other members of their health care team. To contact the Community Health Workers Team call 1-844-385-2192, Nebraska Relay Service 711.

Chronic Care/Disease Management Programs As a part of Nebraska Total Care services, Management Programs (CCMP) are offered to members. Chronic Care Management/Disease Management is the concept of reducing healthcare costs and improving quality of life for individuals with a chronic condition, through integrative care. Chronic care management supports the physician or practitioner/patient relationship and plan of care; emphasizes prevention of exacerbations and complications using evidence-based practice guidelines and patient empowerment strategies, and evaluates clinical, humanistic and economic outcomes on an ongoing basis with the goal of improving overall health. Nebraska Total Care programs include but are not limited to: asthma, diabetes, congestive heart failure, depression, anxiety, perinatal depression, perinatal substance abuse and ADHD. Our programs promote a coordinated, proactive, disease-specific approach to management that will improve members’ self-management of their condition; improve clinical outcomes; and control high costs associated with chronic medical conditions. Not all members having the targeted diagnoses will be enrolled in the CCMP. Members with selected disease states will be stratified into risk groups that will determine need and level of intervention. High-risk members with co-morbid or complex conditions will be referred for care management program evaluation. To refer a member for chronic care management call Nebraska Total Care Health Coaches at 1- 844-385-2192, Nebraska Relay Service 711.

Coordination of Care Our Care Coordinators are not licensed clinical staff and cannot make clinical decisions about what level of care is needed or assess members who are in crisis. Our Care Coordination functions include: • Coordinate with Nebraska Total Care, member advocates or providers for members who may need behavioral health services; • Assist members with locating a Provider; and • Coordinate requests for out-of-network providers by determining need/access issues involved. Our coordination of care process is designed to ensure the coordination and continuity of care during the movement between providers and settings. During transitions, patients with complex medical needs are at risk for poorer outcomes due to medication errors and other errors of communication among the involved providers and between providers and patients/caregivers. Continuity of health care means different things to different types of caregivers, and can be of several types: • Continuity of information. It includes that information on prior events is used to give care that is appropriate to the patient's current circumstance.

39 • Continuity of personal relationships, recognizing that an ongoing relationship between patients and providers is the foundation that connects care over time and bridges discontinuous events. • Continuity of clinical management. Providers must adhere to the Covered Services & Authorization Guidelines (CSAG) located on the website at NebraskaTotalCare.com when rendering services. We do not retroactively authorize treatment.

Communication with Primary Care Provider Nebraska Total Care requires Primary Care Provider (PCPs) to consult with their member’s behavioral health providers. In many cases the PCP has extensive knowledge about the member’s medical condition, mental status, psychosocial functioning, and family situation. Communication of this information at the point of referral or during the course of treatment is encouraged with member consent, when required. Providers can identify the name and number for a member’s PCP on the front-side of the member ID Card. Practitioners/Providers should refer members with known or suspected untreated physical health problems or disorders to the PCP for examination and treatment. Providers should communicate not only with the member’s PCP whenever there is a behavioral health problem or treatment plan that can affect the member’s medical condition or the treatment being rendered by the PCP, but also with other behavioral health clinicians who may be providing service to the member. Examples of some of the items to be communicated include: • Prescription medication, especially when the medication has potential side effects, such as weight gain, that could complicate medical conditions, such as diabetes; • The member is known to abuse over-the-counter, prescription or illegal substances in a manner that can adversely affect medical or behavioral health treatment; • The member has lab work indicating need for PCP review and consult; • The member is receiving treatment for a behavioral health diagnosis that can be misdiagnosed as a physical disorder (panic symptoms can be confused with heart attack symptoms); • The member’s progress toward meeting the goals established in their treatment plan. We provide a form for your convenience in communicating with PCP and other providers (available at NebraskaTotalCare.com) and recommend that you use all available means to coordinate treatment for members in your care. All communication attempts and coordination activities must be clearly documented in the member’s medical record. If you are unable to locate or contact other providers serving your member, please contact us for additional information. We require that providers report specific clinical information to the member’s PCP in order to preserve the continuity of the treatment process. With appropriate written consent from the member, it is the provider’s responsibility to keep the member’s PCP abreast of the member’s treatment status and progress in a consistent and reliable manner. Such consent shall meet the requirements set forth in 42 CFR 2.00 et seq., when applicable. If the member requests this information not be given to their PCP, the provider must document this refusal in the member’s treatment record, and if possible, the reason why. The following information should be included in the report to the PCP: • A copy or summary of the intake assessment • Written notification of member’s noncompliance with treatment plan (if applicable)

40 • Member’s completion of treatment • The results of an initial psychiatric evaluation, and initiation of and major changes in psychotropic medication(s) • The results of functional assessments Caution must be exercised in conveying information regarding substance use disorders, which is protected under separate federal law. We monitor communication with the PCP and other caregivers through audits. Failure to adhere to these requirements can be cause for termination from the network. Providers must adhere to the Covered Services & Authorization Guidelines (CSAG) located on the website at NebraskaTotalCare.com when rendering services. We do not retroactively authorize treatment.

Continuity of Care When members are newly enrolled and have been previously receiving behavioral health services, we will continue to authorize care as needed to minimize disruption and promote continuity of care. We will work with non-participating practitioners/providers (those that are not contracted and credentialed in our provider network) to continue treatment or create a transition plan to facilitate transfer to a participating provider.

EARLY AND PERIODIC SCREENING, DIAGNOSTIC & TREATMENT The Early and Periodic Screening, Diagnostic and Treatment (EPSDT) service is Medicaid’s comprehensive and preventive child health program for individuals under the age of 21, provision of which is mandated by state and federal law. EPSDT services include periodic screening, vision, dental and hearing services. In addition, the need for corrective treatment disclosed by such child health screenings must be arranged (directly or through referral) even if the service is not available under the State’s Medicaid plan to the rest of the Medicaid population. Nebraska Total Care and its providers will provide the full range of EPSDT services as defined in, and in accordance with, Nebraska state regulations and American Medical Association (AMA) policies and procedures for EPSDT services. Such services shall include, without limitation, periodic health screenings and appropriate up to date immunization schedules using the Advisory Committee on Immunization Practices (ACIP) recommended immunization schedule and the American Academy of Pediatrics periodicity schedule for pediatric preventative care. This includes provision of all medically necessary services whether specified in the core benefits and services or not, except those services (carved out/excluded/prohibited services) that have been identified herein. The following minimum elements are to be included in the periodic health screening assessment: • Comprehensive health and development history (including assessment of both physical and mental development); • Comprehensive unclothed physical examination; • Immunizations appropriate to age and health history; • Assessment of nutritional status;

41 • Laboratory tests (including finger stick hematocrit, urinalysis [dip-stick], sickle cell screen, if not previously performed); blood lead levels must be tested pursuant to the EPSDT provider manual; • Developmental assessment; • Vision screening and services, including at a minimum, diagnosis and treatment for defects in vision, including eyeglasses; • Dental screening and services coordinated through Fee For Service; • Hearing screening and services, including at a minimum, diagnosis and treatment for defects in hearing, including hearing aids; • Health education and anticipatory guidance; • Annual Well-Child visits for members under age 21. Provision of all components of the EPSDT service must be clearly documented in the PCP’s medical record for each member.

EMERGENCY CARE SERVICES Nebraska Total Care’ defines an emergency medical condition as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in: • Placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy • Serious impairments of bodily functions, or • Serious dysfunction of any bodily organ or part as per 42 CFR 438.114.(a) Nebraska Total Care does not limit what constitutes an emergency medical condition on the basis of lists of diagnoses or symptoms. Members may access emergency services at any time without prior authorization or prior contact with Nebraska Total Care. Providers should inform members that if they are unsure as to the urgency or emergency of the situation, they are encouraged to contact their Primary Care Provider (PCP) and/or Nebraska Total Care’s 24 hour nurse advice hotline for assistance; however, this is not a requirement to access emergency services. Nebraska Total Care contracts with emergency services providers as well as non-emergency providers who can address the member’s non-emergency care issues occurring after regular business hours or on weekends. Emergency services are covered by Nebraska Total Care when furnished by a qualified provider, including non-network providers, and will be covered until the member is stabilized. Any screening examination services conducted to determine whether an emergency medical condition exists will also be covered by Nebraska Total Care. Emergency services will cover and reimburse regardless of whether the provider is in Nebraska Total Care’s provider network and will not deny payment for treatment obtained under either of the following circumstances: • A member had an emergency medical condition, including cases in which the absence of immediate medical attention would not have had the outcomes specified in the definition of Emergency Medical Condition; or • A representative from the Plan instructs the member to seek emergency services. Once the member’s emergency medical condition is stabilized, Nebraska Total Care requires Notification for hospital admission or Prior Authorization for follow-up care as noted elsewhere in this manual.

42 MEDICAL NECESSITY “Medical Necessity” or “Medically Necessary Care” means any health care services and supplies that are medically appropriate and: • Necessary to meet the basic health needs of the member. • Rendered in the most cost-efficient manner and type of setting appropriate for the delivery of the covered service. • Consistent in type, frequency, and duration of treatment with scientifically-based guidelines of national medical, research, or health care coverage organizations or governmental agencies. • Consistent with the diagnosis of the condition. • Required for means other than convenience of the client or his/her physician. • No more intrusive or restrictive than necessary to provide a proper balance of safety, effectiveness, and efficiency. • Of demonstrated value. • No more intensive level of service than can be safely provided.

UTILIZATION MANAGEMENT The Nebraska Total Care Utilization Management Program (UMP) is designed to ensure members of Nebraska Total Care Network receive access to the right care at the right place and right time. Our program is comprehensive and applies to all eligible members across all eligibility types, age categories, and range of diagnoses. The UMP incorporates all care settings including preventive care, emergency care, primary care, specialty care, , short-term care, Health Homes, behavioral health, maternity care and ancillary care services. Nebraska Total Care UMP seeks to optimize a member’s health status, sense of well-being, productivity, and access to quality health care, while at the same time actively managing cost trends. The UMP aims to provide services that are a covered benefit, medically necessary, appropriate to the patient's condition, rendered in the appropriate setting and meet professionally recognized standards of care. Our program goals include: • Development of quality standards for the region with the collaboration of the Provider Standards Committee. • Monitoring utilization patterns to guard against over- or under- utilization • Development and distribution of clinical practice guidelines to providers to promote improved clinical outcomes and satisfaction • Identification and provision of case and/or population management for members at risk for significant health expenses or ongoing care • Development of an infrastructure to ensure that all Nebraska Total Care members establish relationships with their PCPs to obtain preventive care • Implementation of programs that encourage preventive services and chronic condition self-management • Creation of partnerships with members/providers to enhance cooperation and support for UMP goals

43 Prior Authorizations Failure to obtain required approval or prior authorization may result in a denied claim(s). All services are subject to benefit coverage, limitations, and exclusions as described in applicable plan coverage guidelines. Nebraska Total Care providers are contractually prohibited from holding any Nebraska Total Care member financially liable for any service administratively denied by Nebraska Total Care for the failure of the provider to obtain timely authorization. All out-of-network services require prior authorization except for family planning, emergency room, post-stabilization services and table top x-rays. Nebraska Total Care does not reward practitioners, providers, or employees who perform utilization reviews, including those of the delegated entities for issuing denials of coverage or care. UM decision-making is based only on appropriateness of care, service, and existence of coverage. Financial incentives for UM decision makers do not encourage decisions that result in underutilization. Utilization denials are based on lack of medical necessity or lack of covered benefit. Nebraska Total Care and its delegated health plan partners have utilization and claims management systems in place in order to identify, track, and monitor the care provided and to ensure appropriate healthcare is provided to the members. Nebraska Total Care has implemented the following measures to ensure appropriate utilization of health care: • A process to monitor for under and overutilization of services and take the appropriate intervention when identified • A system in place to support the analysis of utilization statistics, identification of potential quality of care issues, implementation of intervention plans and evaluation of the effectiveness of the actions taken • A process to support continuity of care across the health care continuum

Services That Require Prior Authorization Ancillary Services • Air ambulance transport (non-emergent fixed wing airplane) • Durable Medical Equipment above $750 • Private Duty Nursing • Furnished Medical Supplies and DME • Orthotics/Prosthetics • Genetic testing • Quantitative urine drug screen Out-Of-Network Providers • All out-of-network providers require prior authorization excluding emergency room services Procedures/Services • Potentially cosmetic • Bariatric surgery • High tech imaging administered by NIA, i.e. CT, MRI, PET at RadMD.com • Obstetrical ultrasound — Two allowed in nine months; prior authorization required for additional u/s except if rendered by a perinatologist • Pain management

44 Inpatient Authorization All elective/scheduled admission notifications requested at least five days prior to the scheduled date of admit including but not limited to: • Medical Admissions • Surgical Admissions • All services performed in out-of-network facilities • Acute Rehabilitation Facilities • Skilled Nursing Facilities • Behavioral Health/Substance Use Disorder • Observation stays exceeding 23 hours require Inpatient Authorization/Concurrent Review • Behavioral Health Admissions • Partial Inpatient, PRTF, and/or Psychiatric Residential services Outpatient Programs • IOP and Partial Hospitalization • Behavioral Health Rehabilitation services • Certain behavioral health outpatient services Please visit NebraskaTotalCare.com and use the Pre-Auth Check tool to determine if a service requires Prior Authorization.

Procedures for Requesting a Medical Prior-Authorization The preferred method for submitting authorizations is through the secure provider portal NebraskaTotalCare.com. The provider must be a registered user on the secure provider portal. If the provider is not already a registered user on the secure provider portal and needs assistance or training on submitting prior authorizations, the provider should contact his or her dedicated Provider Relations Representative. Other methods of submitting the prior authorization requests are as follows: • Call the Medical Management Department at 1-844-385-2192, Nebraska Relay Service 711. Please note: The Medical Management normal business hours are Monday – Friday 8 a.m. to 5 p.m. CST. Voicemails left after hours and will be responded to on the next business day. • Fax prior authorization requests utilizing the Prior Authorization fax forms posted on NebraskaTotalCare.com. Please note: faxes will not be monitored after hours and will be responded to on the next business day.

Timeframes for Prior Authorization Requests and Notifications Authorization must be obtained prior to the delivery of certain elective and scheduled services. The following timeframes are required for prior authorization and notification.

Service Type Timeframe Scheduled admissions Prior Authorization required five business days prior to the scheduled admission date Elective outpatient services Prior Authorization required five business days prior to the elective outpatient admission date Emergent inpatient admissions Notification within two business day

45 Service Type Timeframe Observation Notification within one business day for non- participating providers (all observation services for non-participating providers require authorization) Unplanned Observation – greater than 23 Requires inpatient prior authorization within one hours business day Planned Observation – greater than 23 Prior Authorization required five business days hours prior to the scheduled service admission date Emergency room and post stabilization, Notification within two business day urgent care and crisis intervention Maternity admissions Notification within one business day, with delivery outcome Newborn admissions Notification within one business day Neonatal Intensive Care Unit (NICU) Prior Authorization within one business day admissions Behavioral Health Services See “Inpatient Notification Process” below

Any prior authorization request that is faxed or sent via the website after normal business hours (Monday – Friday 8 a.m. to 5 p.m. CST, excluding holidays) will be processed the next business day. Failure to obtain authorization may result in administrative claim denials.

Authorization Determination Timelines Nebraska Total Care decisions are made as expeditiously as the member’s health condition requires. Type Timeframe Preservice/Urgent 3 calendar days Preservice/Non-Urgent 14 calendar days Concurrent review 3 calendar days

Clinical Information Nebraska Total Care clinical staff request clinical information minimally necessary for clinical decision-making. All clinical information is collected according to federal and state regulations regarding the confidentiality of medical information. Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), Nebraska Total Care is entitled to request and receive protected health information (PHI) for purposes of treatment, payment and healthcare operations, without the authorization of the member. Information necessary for authorization of covered services may include but is not limited to: • Member’s name, member ID number • Provider’s name and telephone number • Facility name, if the request is for an inpatient admission or outpatient facility services • Provider location if the request is for an ambulatory or office procedure • Reason for the authorization request (e.g. primary and secondary diagnosis, planned surgical procedures, surgery date)

46 • Relevant clinical information (e.g. past/proposed treatment plan, surgical procedure, and diagnostic procedures to support the appropriateness and level of service proposed) • Admission date or proposed surgery date, if the request is for a surgical procedure • Discharge plans • For obstetrical admissions, the date and method of delivery, estimated date of confinement, and information related to the newborn or neonate including the date of birth and gender of infant must be provided to Nebraska Total Care within 1 business day or before discharge. If additional clinical information is required, a nurse or medical service representative will notify the caller of the specific information needed to complete the authorization process.

Clinical Decisions Nebraska Total Care affirms that utilization management decision making is based on appropriateness of care and service and the existence of coverage. Nebraska Total Care does not reward practitioners or other individuals for issuing denials of service or care. Delegated providers must ensure that compensation to individuals or entities that conduct utilization management activities is not structured so as to provide incentives for the individual or entity to deny, limit, or discontinue medically necessary services to any member. The treating physician, in conjunction with the member, is responsible for making all clinical decisions regarding the care and treatment of the member. The PCP, in consultation with the Nebraska Total Care Medical Director, is responsible for making utilization management (UM) decisions in accordance with the member’s plan of covered benefits and established PC criteria. Failure to obtain authorization for services that require plan approval may result in payment denials.

Review Criteria Nebraska Total Care has adopted utilization review criteria developed by McKesson InterQual® products to determine medical necessity for healthcare services. InterQual appropriateness criteria are developed by specialists representing a national panel from community-based and academic practice. InterQual criteria cover medical and surgical admissions, outpatient procedures, referrals to specialists, and ancillary services. Criteria are established and periodically evaluated and updated with appropriate involvement from physicians. InterQual is utilized as a screening guide and is not intended to be a substitute for practitioner judgment. Substance Use services are authorized utilizing ASAM criteria. Mental Health rehab services are reviewed based on a rehab specific policy, which can be found at NebraskaTotalCare.com. The Medical Director, or other healthcare professional that has appropriate clinical expertise in treating the member’s condition or disease, reviews all potential adverse determination and will make a decision in accordance with currently accepted medical or healthcare practices, taking into account special circumstances of each case that may require deviation from the norm in the screening criteria. Providers may obtain the criteria used to make a specific adverse determination by contacting Medical Management at 1-844-385-2192, Nebraska Relay Service 711. Practitioners also have the opportunity to discuss any adverse decisions with a physician or other appropriate reviewer at the time of notification to the requesting practitioner/facility of an adverse determination. The Medical Director may be contacted through Provider Services by calling Nebraska Total Care main toll-free phone number at 1-844-385-2192, Nebraska Relay Service 711 and asking for a Peer Review with the Medical Director. A care manager may also coordinate communication between the Medical Director and requesting practitioner.

47 Members or healthcare professionals with the member’s consent may request an appeal related to a medical necessity decision made during the authorization or concurrent review process orally or in writing to: Nebraska Total Care Attn: Complaint and Grievance Coordinator 2525 N 117th Ave, Suite 100 Omaha, NE 68164 The member or provider may file an expedited appeal either verbally or in writing. No additional member follow-up is required.

Second Opinion Members or a healthcare professional with the member’s consent may request and receive a second opinion from a qualified professional within the Nebraska Total Care network. If there is not an appropriate provider to render the second opinion within the network, the member may obtain the second opinion from an out-of-network provider at no cost to the member. Out-of- network and in-network providers require prior authorization by Nebraska Total Care when performing second opinions.

Assistant Surgeon Reimbursement for an assistant surgeon’s service is based on the procedure itself and the assistant surgeon’s presence at the time of the procedure. Hospital medical staff by-laws that require an assistant surgeon be present for a designated procedure are not in and of themselves grounds for reimbursement as they may not constitute medical necessity, nor is reimbursement guaranteed when the patient or family requests that an assistant surgeon be present for the surgery, unless medical necessity is indicated.

New Technology Nebraska Total Care evaluates the inclusion of new technology and the new application of existing technology for coverage determination. This may include medical procedures, drugs and/or devices. The Medical Director and/or Medical Management staff may identify relevant topics for review pertinent to the Nebraska Total Care population. The Clinical Policy Committee (CPC) reviews all requests for coverage and makes a determination regarding any benefit changes that are indicated. If you need a new technology benefit determination or have an individual case review for new technology, please contact the Medical Management department at 1-844-385-2192, Nebraska Relay Service 711.

Notification of Pregnancy Members that become pregnant while covered by Nebraska Total Care may remain a Nebraska Total Care member during their pregnancy. The managing physician should notify the Nebraska Total Care prenatal team by completing the Notification of Pregnancy (NOP) and / or the MLTC Obstetric Needs Assessment Form (ONAF) form within five days of the first prenatal visit. Providers are expected to identify the estimated date of confinement and delivery facility. See the Care Management section for information related to our Start Smart for Your Baby® program and our 17-P program for women with a history of early delivery.

Concurrent Review and Discharge Planning Nurse and other appropriately licensed care managers, as appropriate, perform ongoing concurrent review for inpatient admissions through onsite or telephonic methods through contact with the hospital’s Utilization and Discharge Planning departments and when necessary,

48 with the member’s attending physician. The care manager will review the member’s current status, treatment plan and any results of diagnostic testing or procedures to determine ongoing medical necessity and appropriate level of care. Concurrent review decisions will be made within three calendar days of receipt of clinical information. For length of stay extension request, clinical information must be submitted by 3 p.m. CST on the day review is due. Written or electronic notification includes the number of days of service approved, and the next review date. Routine, uncomplicated vaginal or C-section delivery does not require concurrent review, however; the hospital must notify Nebraska Total Care within one business day of delivery with complete information regarding the delivery status and condition of the newborn.

Retrospective Review To request retro-authorization: • Provider will submit a retro-authorization request through the standard authorization request channels (phone, fax, portal) • Provider explicitly identifies in the submission that they are making a retro-authorization request • Nebraska Total Care Utilization Management will receive the request and,

o Determine if it has been made timely based on plan notification of eligibility o If the authorization request is timely, the retro authorization will be reviewed against Medical Necessity Criteria o If the authorization request is not timely, it will be administratively non-authorized • For retro-authorization requests received timely and reviewed for Medical Necessity an authorization determination will be made and communicated to the provider • For retro-authorizations that are not approved upon review, appeal rights apply, and signed release to act on the member’s behalf if appealing a retro authorization applies in line with Nebraska Total Care’s existing appeals policy Nebraska Total Care will not retroactively authorize routine services, except in cases where one of the valid extenuating circumstances is documented: • Services authorized by another payor who subsequently determined member was not eligible at the time of services • Member received retro-eligibility from Department of Health and Human Services, Division of Medicaid and Long-Term Care • Services occurred during a transition of care period between two Heritage Health Managed Care Organizations • Member was not capable of providing insurance information due to incapacitation

Speech, Occupational or Physical Therapy Services Nebraska Total Care offers our members access to all covered, medically necessary outpatient physical, occupational and speech therapy services. Physical, occupational, and speech therapy services are managed by the Nebraska Total Care utilization management team which employs PT/OT/ST clinical reviewers. PT/OT/ST services require prior authorization, for all members. Treatment request forms and information on the authorization process for these services can be found at NebraskaTotalCare.com

49 All PT/OT/ST claims must contain the appropriate modifier when submitted to the health plan in order to ensure appropriate adjudication. Failure to include a specialty modifier (GN, GO, GP), may result in the inability to process your claim. Providers are responsible for ensuring that members have not exhausted their PT/OT/ST benefit and/or has a restorative benefit prior to providing services.

Advanced Diagnostic Imaging As part of a continued commitment to further improve the quality of advanced imaging care delivered to our members, Nebraska Total Care is using National Imaging Associates (NIA) to provide prior authorization services and utilization. NIA focuses on radiation awareness designed to assist providers in managing imaging services in the safest and most effective way possible. Prior authorization is required for the following outpatient radiology procedures: • CT /CTA • MRI/MRA

Key Provisions • Emergency room, observation and inpatient imaging procedures do not require authorization. • It is the responsibility of the ordering physician to obtain authorization. • Providers rendering the above services should verify that the necessary authorization has been obtained. Failure to do so may result in claim non-payment. To reach NIA and obtain authorization, please call 1-844-385-2192, Nebraska Relay Service 711 and follow the prompt for radiology authorizations. NIA also provides an interactive website, which may be used to obtain on-line authorizations. Please visit RadMD.com for more information or call our Provider Services department.

Behavioral Health Medical Necessity Criteria and Tools Our utilization management decisions are based on Medical Necessity and established Clinical Practice Guidelines. We do not reimburse for unauthorized services and each agreement with us precludes providers from balance billing (billing a member directly) for covered services with the exception of copayment and/or deductible collection, if applicable. Our authorization of covered services is an indication of medical necessity, not a confirmation of member eligibility, and not a guarantee of payment. Member coverage is not an entitlement to utilization of all covered benefits, but indicates services that are available when medical necessity is satisfied. The application of Medical Necessity to Medicaid Services is required under Title XIX of the Social Security Act, Sections 1902 and 1903, and mandates utilization control of all Medicaid services under regulations found at Title 42, Code of Federal Regulations, Part 456. Member benefit limits apply for a calendar year regardless of the number of different behavioral health practitioners providing treatment for the Member. Network Providers are expected to work closely with our Utilization Management department in exercising judicious use of a member’s benefit and to carefully explain the treatment plan to the member in accordance with the member’s benefits offered by Nebraska Total Care. We use InterQual Criteria for mental health for both adult and pediatric guidelines and the American Society of Addiction Medicine Patient Placement Criteria (ASAM) for substance abuse MNC. InterQual is a nationally recognized instrument that provides a consistent, evidence-

50 based platform for care decisions and promotes appropriate use of services and improved health outcomes. ASAM and the McKesson InterQual criteria sets are proprietary and cannot be distributed in full, however, a copy of the specific criteria relevant to any individual need for authorization is available upon request. Both ASAM and InterQual criteria are reviewed on an annual basis by our Provider Advisory Committee that is comprised of Network Providers as well as our clinical staff. We are committed to the delivery of appropriate service and coverage, and offers no organizational incentives, including compensation, to any employed or contracted UM staff based on the quantity or type of utilization decisions rendered. Review decisions are based only on appropriateness of care and service criteria, and UM staff is encouraged to bring inappropriate care or service decisions to the attention of the Medical Director.

Inpatient Notification Process Emergency Behavioral Healthcare requests indicate a condition in clinical practice that requires immediate intervention to prevent death or serious harm (to the member or others) or acute deterioration of the member’s clinical state, such that gross impairment of functioning exists and is likely to result in compromise of the member’s safety. An emergency is characterized by sudden onset, rapid deterioration of cognition, judgment or behavioral functioning and is time limited in intensity and duration (usually occurs in seconds or minutes, rarely hours, rather than days or weeks). Thus, elements of both time and severity are inherent in the definition of an emergency. All inpatient admissions require notification within 24 hours of admission. Failure to provide notification may result in an administrative denial. The number of initial days authorized is dependent on medical necessity and continued stay is approved or denied based on the findings in concurrent reviews. The receiving hospital should also notify us of the admission to acute care when the consumer arrives and is admitted. The facility will be required to provide clinical review information the next business day and at subsequent intervals for concurrent review depending upon the consumer’s specific symptoms and progress. Members meeting criteria for inpatient treatment must be admitted to a contracted hospital or crisis stabilization unit. Members in need of emergency and/or after hours care should be referred to the nearest participating facility for evaluation and treatment, if necessary. The following information must be readily available for the Utilization Manager when requesting initial authorization for inpatient care: • Name, age, health plan and identification number of the member; • Diagnosis, indicators, and nature of the immediate crisis; • Alternative treatment provided or considered; • Treatment goals, estimated length of stay, and discharge plans; • Family or social support system; • Current mental status For a listing of providers participating in our network, please refer to our online Provider Directory at NebraskaTotalCare.com you can also contact your network representative by calling 1-844-385-2192, Nebraska Relay Service 711.

Outpatient Notification Process Network providers need to adhere to the Covered Services & Authorization Guidelines located at NebraskaTotalCare.com when rendering services. Please refer to the Covered Services & Authorization Guidelines to identify which services require authorization. When authorizations

51 are required, Network Providers must contact us to obtain authorized sessions for continued services. We do not retroactively authorize treatment. For prior authorizations during normal business hours, Network Providers should call or contact us at: 1-844-385-2192, Nebraska Relay Service 711.

Outpatient Treatment Request (OTR)/ Requesting Additional Sessions When requesting sessions for those outpatient services that require authorization, the network practitioner must complete an Outpatient Treatment Request (OTR) form and fax the completed form to us 1-866-593-1955 or submit electronically for clinical review. Network Practitioners may call the Customer Service department at 1-844-385-2192, Nebraska Relay Service 711 to check the status of an OTR. Network practitioners should allow up to fourteen (14) business days to process non-urgent requests. OTR forms for services requiring authorization are located at NebraskaTotalCare.com. Important: • The OTR must be completed in its entirety. The diagnoses as well as all other clinical information must be evident. Failure to complete an OTR in its entirety can result in authorization delay and/or denials. • We will not retroactively certify routine services. The dates of the authorization request must correspond to the dates of expected services. Treatment must occur within the dates of the authorization. Our utilization management decisions are based on medical necessity and established Clinical Practice Guidelines. We do not reimburse for unauthorized services and each provider agreement with us precludes network providers from balance billing (billing a member directly) for covered services with the exception of copayment and/or deductible collection, if applicable. Our authorization of covered services is an indication of medical necessity, not a confirmation of member eligibility, and not a guarantee of payment.

Guidelines for Psychological Testing Psychological testing must be prior authorized for outpatient services. Testing, with prior- authorization, may be used to clarify questions about a diagnosis as it directly relates to treatment. OTR forms for services requiring authorization are located at NebraskaTotalCare.com. It is important to note: • Testing will not be authorized by us for ruling out a medical condition. • Testing is not used to confirm previous results that are not expected to change. • A comprehensive initial diagnostic interview (procedure code 90791) should be conducted by the requesting Psychologist prior to requesting authorization for testing. No authorization is required for this assessment if the practitioner is contracted and credentialed with us. • Providers should submit a request for Psychological Testing that includes the specific tests to be performed. Providers may access our Psychological Testing Authorization Request Form on the website. • Testing requested by the court or state agencies for the purpose of placement, is not considered medically necessary and may not be reimbursed.

52 Adverse Benefit Determination (Notice of Action) When we determine that a specific service does not meet criteria and will therefore not be authorized, we will submit a written adverse benefit determination to the treating network practitioner or provider rendering the service(s) and the member. The notification will include the following information/ instructions: • The reason(s) for the proposed action in clearly understandable language. • A reference to the criteria, guideline, benefit provision, or protocol used in the decision, communicated in an easy to understand summary. • A statement that the criteria, guideline, benefit provision, or protocol will be provided upon request. • Information on how the provider may contact the Peer Reviewer to discuss decisions and proposed actions. When a determination is made where no peer-to-peer conversation has occurred, the Peer Reviewer who made the determination (or another Peer Reviewer if the original Peer Reviewer is unavailable) will be available within one (1) business day of a request by the treating provider to discuss the determination. • Instructions for requesting an appeal including the right to submit written comments or documents with the appeal request; the member’s right to appoint a representative to assist them with the appeal, and the timeframe for making the appeal decision. • For all urgent precertification and concurrent review clinical adverse decisions, and instructions for requesting an expedited appeal. • The right to have benefits continues pending resolution of the appeal, how to request that benefits be continued, and the circumstances under which the member may be required to pay the costs of these services.

Peer Clinical Review Process If the Utilization Manager is unable to certify the requested level of care based on the information provided, the Utilization Manager will initiate the peer review process. For outpatient service requests, the clinical information submitted will be forwarded to an appropriate clinician of like specialty of the requesting provider for review and response. When a determination is made where no peer-to-peer conversation has occurred, a provider can request to speak with the Clinical Consultant who made the determination. If the member is dissatisfied with the decision of the medical director, the member may within ten (10) Calendar Days of notification of the decision file a written or oral notice of appeal, with an oral filing followed by a written, signed notice of appeal within five (5) Calendar Days, with Nebraska Total Care to be heard by a Peer Review committee. As a result of the Peer Clinical Review process, we will make a decision to approve, modify, or deny authorization for services. Treating practitioners may request a copy of the medical necessity criteria used in any denial decision. The treating practitioner may request to speak with the Peer Reviewer who made the determination after any denial decision. If you would like to discuss a denial decision, contact us at 1-844-385-2192, Nebraska Relay Service 711. In addition, if we determine that a member is in need of services that are not covered benefits, the member will be referred to an appropriate provider and we will continue to coordinate care including discharge planning.

53 Clinical Training The Provider Training Team will provide training for network providers, stakeholders, and caregivers within our network. Training opportunities will support provider’s ability to provide quality services to members. All trainings are provided free of charge, and are conducted in person, group, regional, facility based, and/or remote webinar trainings. Training is available for behavioral health and physical health providers, stakeholder groups, caregivers, and other non- clinical professions. Topics offered to providers include, but are not limited to: • Motivational Interviewing (certified trainers) • Mental Health First Aid (certified trainers) • Screening Brief Intervention and Referral to Treatment (certified trainers) • CPI Dementia Training (certified trainers) • Alzheimer’s Training (certified to offer train-the-trainer courses) • PCP Toolkits • Behavioral health/physical health screening & referral • Recovery Principles • Integrated Healthcare • Trauma Informed Care • Diagnosis-specific Overviews • Substance Abuse Overview • Stages of Change • SMART Goals • Behavioral Management & De-escalation • Behavioral Management in the Long Term Care Population • HIPAA and Privacy Laws • Cultural Competency • Poverty Competency • Person Centered Approach • Evidence Based Practices (including but not limited to)

o Trauma Focused Cognitive Behavioral Therapy o Recovery Model o Strengths Based Model o Positive Psychology • Peer Support • When to refer to Primary Care • Referral for Care Management • Behavioral Health 101 • Physical Health 101 • Psychiatric Medications • Medical Necessity Criteria

54 The Training team is committed to achieving the following goals: • Promoting provider competence and opportunities for skill-enhancement across disciplines • Promoting member recovery through integrated, member-centered care • Sustaining and expanding the use of Evidence Based Practices (e.g. Motivational Interviewing, Stages of Change, Impact Model, Positive Psychology, Trauma Focused Cognitive Behavioral Therapy • Assisting providers in meeting Mandatory State or Licensure Requirements • Providing Continuing Education credits when applicable The opportunity to provide additional clinical trainings to providers is the responsibility of the Network, Quality, and Training team. The Training Team can be reached directly at [email protected] to request any of the above training topics or request a new topic.

Member Concerns About Provider Members who have concerns about our providers should contact us to register their concerns. All concerns are investigated, and feedback is provided on a timely basis. It is the provider’s responsibility to provide supporting documentation to us if requested. Any validated concern will be taken into consideration when re-credentialing occurs, and can be cause for termination from our provider network.

Monitoring Satisfaction We conduct periodic satisfaction surveys of our members and providers. These surveys enable us to gather useful information to identify areas for improvement. Providers may be requested to participate in the annual survey process. The survey includes a variety of questions designed to address multiple facets of the providers experience with our delivery system should call the Provider Relations department to address concerns as they arise. Feedback from providers enables us to continuously improve systems, policies and procedures. We will also collect feedback from members at the Members Advisory Committee and our Quality Committees.

Critical Incident Reporting A critical incident is defined as any occurrence which is not consistent with the routine operation of a behavioral health provider. It includes, but is not limited to; injuries to members or member advocates, suicide/homicide attempt by a member while in treatment, death due to suicide/homicide, sexual battery, medication errors, member escape or elopement, altercations involving medical interventions, or any other unusual incident that has high risk management implications. Providers will follow the Nebraska DHHS process and requirements for submission of all critical incidents. Upon receipt and notification of critical incident review requests from DHHS, we may require providers to participate in the quality review process.

CLINICAL PRACTICE GUIDELINES

Medical Nebraska Total Care clinical and quality programs are based on evidence based preventive and clinical practice guidelines. Whenever possible, Nebraska Total Care adopts guidelines that are published by nationally recognized organizations or government institutions as well as statewide collaborative and/or a consensus of healthcare professionals in the applicable field.

55 Nebraska Total Care providers are expected to follow these guidelines and adherence to the guidelines will be evaluated at least annually as part of the Quality Improvement Program. Following is a sample of the clinical practice guidelines adopted by Nebraska Total Care. • American Academy of Pediatrics: Recommendations for Preventive Pediatric Health Care • American Diabetes Association: Standards of Medical Care in Diabetes • Center for Disease Control and Prevention (CDC): Adult and Child Immunization Schedules • National Heart, Lung, and Blood Institute: Guidelines for the Diagnosis and Management of Asthma and Guidelines for Management of Sickle Cell • U.S. Preventive Services Task Force Recommendations for Adult Preventive Health For links to the most current version of the guidelines adopted by Nebraska Total Care, visit our website at NebraskaTotalCare.com.

Behavioral Health We have adopted many of the clinical practice guidelines published by the American Psychiatric Association and the American Academy of Child and Adolescent Psychiatry as well as evidence-based practices for a variety of services. Clinical practice guidelines adopted for adults include but are not limited to treatment of: • Major Depressive Disorder • Bipolar Disorder • Substance Use Disorders • Schizophrenia • Post-Traumatic Stress Disorder (PTSD) • Panic Disorders • ADHD • Psychotropic Medication For children, we have adopted guidelines for Depression in Children and Adolescents, Assessment and Treatment of Children and Adolescents with Anxiety Disorders and Attention Deficit/ Hyperactivity Disorder. Clinical practice guidelines may be accessed through our website, or you may request a paper copy of the guidelines by contacting your Network Manager. Copies of our evidence-based practices can be obtained in the same manner. For links to the most current version of the guidelines adopted by Nebraska Total Care, visit our website at NebraskaTotalCare.com.

Speech, Physical or Occupational Therapy The Specialty Therapy and Rehabilitation Services program utilizes current practice guidelines from the respective National Associations for each discipline to help guide reviewers in determining best practices and medical necessity. Some examples of current practice guidelines can be found in the following resources. This list is not all inclusive. Updated resources are utilized as they become available. • Guide to Physical Therapist Practice 3.0. Alexandria, VA: American Physical Therapy Association; 2014. Available at: guidetoptpractice.apta.org (Accessed 4/26/2016.) • American Speech Language hearing Association, Medical Review Guidelines for Speech- Language Pathology Services (2001) • Clark GF. Guidelines for documentation of Occupational Therapy (2003). Am J Occupational Therapy. 2003 Nov-Dec;57(6):646-9

56 PHARMACY Nebraska Total Care is committed to providing appropriate, high quality, and cost effective drug therapy to all Nebraska Total Care members. We work with providers and pharmacists to ensure medications used to treat a variety of conditions and diseases are covered. Nebraska Total Care covers prescription drugs and certain over-the-counter (OTC) drugs when ordered by a Nebraska Medicaid provider. The pharmacy program does not cover all medications. Some medications require prior authorization (PA) or have limitations on age, dosage and/or maximum quantities. This section provides an overview of Nebraska Total Care pharmacy program. For more detailed information and pharmacy claims billing information, please visit our website at NebraskaTotalCare.com.

PREFERRED DRUG LIST (PDL) The Nebraska Medicaid Preferred Drug List (PDL) is maintained by the state Medicaid department can be found online at NebraskaTotalCare.com and describes the circumstances under which contracted pharmacy providers will be reimbursed for medications dispensed to members covered under the program. All drugs covered under the Nebraska Medicaid program are available for Nebraska Total Care members. The PDL includes all drugs available without PA and those agents that have the restrictions. The PA list includes those drugs that require prior authorization for coverage. The PDL is evaluated by the Nebraska Medicaid Department to promote the appropriate and cost-effective use of medications. The Nebraska Total Care Pharmacy and Therapeutics (P&T) committee evaluates medications not covered by the PDL for placement on the formulary. The Committee is composed of the Nebraska Total Care Medical Director, Nebraska Total Care Pharmacy Director, and several Nebraska primary care physicians, and pharmacists. The formulary can be found at NebraskaTotalCare.com and will include any information regarding PA, quantity limits, or step therapy requirements. The PDL and formulary do not: • Require or prohibit the prescribing or dispensing of any medication • Substitute for the independent professional judgment of the provider or pharmacist • Relieve the provider or pharmacist of any obligation to the member or others. The Nebraska Medicaid PDL and Nebraska Total Care formulary includes a broad spectrum of generic and brand name drugs. Some preferred drugs require Prior Authorization (PA). Medications requiring PA are listed with a “PA” notation.

COMPOUNDS Compounded prescriptions must be submitted online and each ingredient must have anactive and valid NDC. Compounded medications may be subject to prior authorization based on ingredients submitted. Compounds that have a commercially available product are not reimbursable. Pharmacy providers can access detailed instructions on how to submit a compound claim by accessing the CVS Payer Sheets .

57 PHARMACY AND THERAPEUTICS COMMITTEE (P&T) The Nebraska Total Care Pharmacy and Therapeutics (P&T) Committee continually evaluates the therapeutic classes included in the formulary. The Committee is composed of the Nebraska Total Care Medical Director, Nebraska Total Care Pharmacist, and several community based primary care physicians and specialists. The primary purpose of the Committee is to assist in developing and monitoring the Nebraska Total Care formulary and to establish programs and procedures that promote the appropriate and cost-effective use of medications. The P&T Committee schedules meetings at least twice yearly, and coordinates reviews with a national P&T Committee which meets at least 4 times a year. Changes to the Nebraska Total Care formulary are done in conjunction with the approval of the State of Nebraska. Nebraska Total Care will meet with the State quarterly to review any proposed changes and update the formulary with any appropriate restrictions accordingly based on the results of both the Nebraska Total Care P&T Committee and the requirements from the State of Nebraska. Nebraska Total Care will follow all State policies regarding member notification when changes are made to the PA list.

UNAPPROVED USE OF PREFERRED MEDICATION Medication coverage under this program is limited to non-experimental indications as approved by the FDA. Other indications may also be covered if they are accepted as safe and effective using current medical and pharmaceutical reference texts and evidence-based medicine. Reimbursement decisions for specific non-approved indications will be made by Nebraska Total Care following requirements in Social Security Act 1927. Experimental drugs and investigational drugs are not eligible for coverage.

PRIOR AUTHORIZATION PROCESS The Nebraska Medicaid PDL and Nebraska Total Care formulary includes a broad spectrum of brand name and generic drugs. Clinicians are encouraged to prescribe from the approved list for their patients who are members of Nebraska Total Care. Some drugs will require PA and that requirement will be indicated on the PDL and formulary. In addition, all brand name drugs not listed on either the PDL or formulary will require prior authorization. If a request for prior authorization is needed the information should be submitted by the physician/clinician, pharmacy to Envolve Pharmacy Solutions on the Nebraska Total Care/Envolve Pharmacy Solutions form: Medication Prior Authorization Request Form. This form should be faxed to Envolve Pharmacy Solutions at 1-866-399-0929. This document is located on the Nebraska Total Care website at NebraskaTotalCare.com. Nebraska Total Care will cover the medication if it is determined that: • The request meets all approved criteria. • Depending on the medication, other medications on the PDL have not worked. All reviews are performed by a licensed clinical pharmacist using the criteria provided by the state of Nebraska Medicaid program or by the Nebraska Total Care P&T Committee. Once approved, Envolve Pharmacy Solutions notifies the physician/clinician and pharmacy by fax. If the clinical information provided does not meet the coverage criteria for the requested medication Nebraska Total Care we will notify the member and physician/clinician and pharmacy of alternatives and provide information regarding the appeal process. Mental health drugs prescribed outside of established limits will be reviewed by a Nebraska licensed child and adolescent psychiatrist.

58 If a patient requires a medication that does not appear on the PDL, the physician/clinician can request a PA for the medication. It is anticipated that such exceptions will be rare and that PDL medications will be appropriate to treat the vast majority of medical conditions. A phone or fax-in process is available for PA requests. Please see Envolve Pharmacy Solutions Contact Information Section below. Envolve Pharmacy Solutions Information Envolve Pharmacy Solutions Prior Authorization Phone: 1-844-330-7852 Prescriber Prior Authorization FAX: 1-866-399-0929 Envolve Pharmacy Solutions Mailing Address Envolve Pharmacy Solutions PA Department 5 River Park Place East, Suite 210 Fresno, CA 93720 CVS Pharmacy Help Desk: 1-888-321-2351 72-Hour Emergency Supply Policy BIN#: 004336 State and federal law require that a pharmacy dispense a 72-hour (3-day) supply of medication to any patient awaiting a PA determination. The purpose is to avoid interruption of current therapy or delay in the initiation of therapy. All participating are authorized to provide a 72-hour supply of medication and will be reimbursed for the ingredient cost and dispensing fee for the 72- hour supply of medication, whether or not the PA request is ultimately approved or denied. Unless specifically instructed otherwise by CVS or Nebraska Total Care, Provider is not authorized to enter overrides for an emergency fill without contacting the Pharmacy Help Desk. The pharmacy must call the CVS Pharmacy Help Desk for a prescription override to submit the 72-hour medication supply for payment. Please call 1-888-321-2351 for the CVS Pharmacy Help Desk.

NEWLY APPROVED PRODUCTS New FDA approved drugs will be evaluated for safety and effectiveness for at least the first 6 months. They will require prior authorization prior to P&T approval If Nebraska Total Care does not grant prior authorization, the member and physician/clinician, and pharmacy will be notified and provided information regarding the appeal process.

STEP THERAPY Some medications listed on the Nebraska Medicaid PDL or Nebraska Total Care formulary may require specific medications to be used before you can receive the step therapy medication. If Nebraska Total Care has a record that the required medication was tried first the step therapy medications are automatically covered. If Nebraska Total Care does not have a record that the required medication was tried, the member or physician/clinician may be required to provide additional information. If Nebraska Total Care does not grant prior authorization the member and physician/clinician, and pharmacy will be notified and provided information regarding the appeal process.

59 PROSPECTIVE DUR RESPONSE REQUIREMENTS • Nebraska Total Care is committed to providing a safe and quality pharmacy benefit. Our pharmacy program will utilize prospective and concurrent (DUR) edits to detect potential problems at the point-of-service. All DUR messages appear in the claim response utilizing NCPDP standards. This allows the provider to receive and act on the appropriate DUR conflict codes. Pharmacy providers can find detailed instructions on the DUR system by accessing the CVS Provider Manual. Benefit Exclusions The following drug categories are not part of the Nebraska Total Care PDL and are not covered by the 72- hour emergency supply policy: • Fertility enhancing drugs • Anorexia, weight loss, or weight gain drugs • Drug Efficacy Study Implementation (DESI) and Identical, Related and Similar (IRS) drugs that are classified as ineffective • Infusion therapy and supplies • Drugs and other agents used for cosmetic purposes or for hair growth • Erectile dysfunction drugs prescribed to treat impotence DESI drugs products and known related drug products are defined as less than effective by the FDA because there is a lack of substantial evidence of effectiveness for all labeling indications and because a compelling justification for their medical need has not been established. State programs may allow coverage of certain DESI drugs. Any DESI drugs that are covered are listed in the PDL.

INJECTABLE DRUGS Injections that are self-administered by the member and/or a family member and appear on the PDL or formulary are covered by the Nebraska Total Care pharmacy program. Insulin pens, Glucagon Kit, Epi-pen, Ana-Kit, Imitrex, and Depo-Provera IM are covered by Nebraska Total Care and do not require a prior authorization. All other injectable drugs require prior authorization unless otherwise noted on the Nebraska Medicaid PDL.

BIOPHARMACEUTICALS AND INJECTABLES A specific list of approved pharmacies can dispense biopharmaceuticals and injectables for Nebraska Total Care. That list of approved Specialty Pharmacies is available at NebraskaTotalCare.com. Nebraska Total Care provides a number of biopharmaceutical products through the Biopharmaceutical Program. Most biopharmaceuticals and injectables require a prior authorization to be approved for payment by Nebraska Total Care; however, prior authorization requirements are programmed specific to the drug as indicated in the list provided in the Biopharmaceutical Program document located at NebraskaTotalCare.com. Follow these guidelines for the most efficient processing of your authorization requests.

60 DISPENSING LIMITS, QUANTITY LIMITS AND AGE LIMITS Drugs may be dispensed up to a maximum 30-day supply for each new or refill non-controlled substance. A total of 80 percent (80%) of the days supplied must have elapsed before the prescription can be refilled. A prescription can be filled after 24 days. Controlled substances can’t be filled until 90% of the day supplied has elapsed. Nebraska Total Care may limit how much of a medication you can get at one time. Some medications on the Nebraska Medicaid PDL or Nebraska Total Care formulary may have age limits. Age limits are set for certain drugs based on Food and Drug Administration (FDA) approved labeling and for safety concerns and quality standards of care. The age limit aligns with current FDA alerts for the appropriate use of pharmaceuticals. Dispensing outside the quantity limit (QL) or age limit (AL) requires prior authorization. If the physician/clinician feels a member has a medical reason for getting a larger amount, he or she can ask for prior authorization. If Nebraska Total Care does not grant prior authorization the member and physician/clinician, and pharmacy will be notified and provided information regarding the appeal process. Effective as of October 16, 2019, Nebraska Total Care members are able to get up to a 90-day prescription fill on maintenance medications. Maintenance medications are used to treat chronic, long-term conditions or illnesses. Nebraska Total Care has a list of 90-Day Maintenance Drugs.

MANDATORY GENERIC SUBSTITUTION When generic drugs are available, the brand name drug will not be covered without Nebraska Total Care prior authorization unless specifically allowed on the Nebraska Medicaid PDL. Generic drugs have the same active ingredient, work the same as brand name drugs, and have lower copayments. If the member or physician/clinician thinks a brand name drug is medically necessary, the physician/clinician can ask for prior authorization. The brand name drug will be covered according to our clinical guidelines if there is a medical reason the member needs the particular brand name drug. If Nebraska Total Care does not grant prior authorization the member and physician/clinician will be notified and provided information regarding the appeal process.

OVER-THE-COUNTER MEDICATIONS The pharmacy program covers a large selection of OTC medications as approved by the Nebraska Medicaid program. All OTC medications must be written on a valid prescription by a licensed physician/clinician in order to be reimbursed.

WORKING WITH THE PHARMACY BENEFIT MANAGER (PBM) Nebraska Total Care works with Envolve Pharmacy Solutions to administer pharmacy benefits, including the prior authorization process. Certain drugs require prior authorization to be approved for payment by Nebraska Total Care.

61 These include: • All medications not listed on the State Preferred Drug List (PDL) that are also not listed on the Nebraska Total Care Value-Add Formulary • Some State PDL and Nebraska Total Care Value-Add formulary drugs (designated prior authorization (PA) on the PDL and formulary) Drug Prior Authorization request are available at Envolve Pharmacy Solutions through phone, fax or online. • Envolve Pharmacy Solutions Telephonic Prior Authorization

o Providers may call Envolve Pharmacy Solutions to initiate a prior authorization by calling 1-844-330-7852 • Fax Prior Authorization Complete the Nebraska Total Care/Envolve Pharmacy Solutions Medication Prior Authorization Request form found on the Nebraska Total Care website at NebraskaTotalCare.com. Select For Providers, Pharmacy, Prior Authorization. FAX to Envolve Pharmacy Solutions at 1-866-399-0929. o Once reviewed and a decision is made, Envolve Pharmacy Solutions notifies the prescriber and pharmacy by FAX. If the review results in a denial, the member receives a letter via mail. o If the clinical information provided does not explain the reason for the requested prior authorization medication, Envolve Pharmacy Solutions responds to the prescriber and pharmacy by FAX, offering PDL alternatives. • Online Prior Authorization

o CoverMyMeds is an online drug prior authorization program through Envolve Pharmacy Solutions that allows prescribers to submit prior authorization requests electronically. Electronic prior authorization (ePA) automates the PA process making it a quick and simple way to complete PA requests. The ePA process is HIPAA compliant and enables faster determinations. You may also use this link to track ePA requests. o CoverMyMeds can be found at covermymeds.com/main/prior-authorization-forms/envolverx/Envolve Pharmacy Solutions Contacts - Prior Authorization Fax: 1-866-399-0929 Web: https://pharmacy.envolvehealth.com/pharmacists/prior_authorization.html Phone: 1-844- 330-7852 (Monday - Friday 8 a.m. to 7 p.m. CST)

Mailing Address: Envolve Pharmacy Solutions PA Department 5 River Park Place East, Suite 210 Fresno, CA 93720 When calling, please have member information, including Medicaid ID number, member date of birth, complete diagnosis, medication history, and current medications readily available. If the request is approved, information in the online pharmacy claims processing system will be changed to allow the specific member to receive the specific drug.

62 If the request is denied, the member and physician/clinician, and pharmacy will be notified and provided information regarding the appeal process. Providers are requested to utilize the PDL when prescribing medications for Nebraska Total Care members. If a pharmacist receives a prescription for a drug that requires a PA request, the pharmacist should attempt to contact the provider to request a change to a product included in the Nebraska Medicaid PDL. In the event that a provider or member disagrees with the decision regarding coverage of a medication, the member or the provider, on the member’s behalf, may submit an appeal, verbally or in writing. For additional information about appeals, please refer to the Appeals section herein.

PHARMACY PORTAL AND PROVIDER LINKS For Access to CVS Pharmacy Portal website click- CVS Provider Portal then click on ‘Sign Up’ that is located just below User Name & Password, then follow the registration process. • CVS Provider Manual • CVS Payer Sheets • CVS Pharmacy - Help Desk and Contact Numbers • Paper Claim Information can be found within the CVS Provider Manual at CVS Provider Manual • MAC Pricing - CVS MAC Pricing

63 PROVIDER RELATIONS AND SERVICES

PROVIDER RELATIONS Nebraska Total Care’s Provider Relations department is committed to supporting our providers as they care for our members. Through provider orientation, ongoing training and support of daily business operations, we will strive to be your partners in good care. Upon credentialing approval and contracting, each provider will be assigned a Provider Relations representative. Within 30 days of the provider’s effective date, the Provider Relations representative will contact the provider to schedule an orientation.

Reasons to Contact a Provider Relations Representative • Claims Research/resolution • Authorization inquires • Schedule an in-service training for new staff • Conduct ongoing education for existing staff • Obtain clarification of policies and procedures • Obtain clarification of a provider contract • Request fee schedule information • Obtain membership roster • Obtaining Provider Profiles • Learn how to use electronic solutions on web authorizations, claims submissions and member eligibility • Open/close patient panel • Specialty therapy

o Request training on therapy (PT/OT/ST) review process o Training on SMART goals and the medical necessity policy

PROVIDER SERVICES Provider Services is available at 1-844-385-2192, Nebraska Relay Service 711 Monday through Friday 7 a.m. to 8 p.m. CST.

64 CREDENTIALING AND RE-CREDENTIALING

OVERVIEW The purpose of the credentialing and re-credentialing process is to help make certain that Nebraska Total Care maintains a high quality healthcare delivery system. The credentialing and re-credentialing process helps achieve this aim by validating the professional competency and conduct of our providers. This includes verifying licensure, board certification, and education, and identification of adverse actions, including malpractice or negligence claims, through the applicable state and federal agencies and the National Practitioner Data Base. Participating providers must meet the criteria established by Nebraska Total Care, as well as government regulations and standards of accrediting bodies, and must be enrolled with Nebraska Medicaid. Nebraska Total Care requires re-credentialing at a minimum of every 3 years because it is essential that we maintain current provider professional information. This information is also critical for Nebraska Total Care’s members, who depend on the accuracy of the information in its provider directory. Note: In order to maintain a current provider profile, providers are required to notify Nebraska Total Care of any relevant changes to their credentialing information in a timely manner.

WHICH PROVIDERS MUST BE CREDENTIALED? All of the following providers are required to be credentialed:

Medical practitioners • Medical doctors • Oral surgeons • Chiropractors • Osteopaths • Podiatrists • Nurse practitioners • Other medical practitioners

Behavioral healthcare practitioners • Psychiatrists and other physicians • Addiction medicine specialists • Doctoral or master’s-level psychologists • Master’s-level clinical social workers • Master’s-level clinical nurse specialists or psychiatric nurse practitioners • Other licensed behavioral healthcare specialists

65 INFORMATION PROVIDED AT CREDENTIALING All new practitioners and those adding practitioners to their current practice must submit at a minimum the following information when applying for participation with Nebraska Total Care: • A completed, signed and dated Credentialing application • Providers can authorize Nebraska Total Care access to their information on file with the CAQH (Council for Affordable Quality Health Care) at CAQH.org • A signed attestation of the correctness and completeness of the application, history of loss of license and/or clinical privileges, disciplinary actions, and/or felony convictions; lack of current illegal substance registration and/or alcohol abuse; mental and physical competence, and ability to perform the essential functions of the position, with or without accommodation (attestation must be no more than 120 days at time of submission for enrollment) • Copy of current malpractice insurance policy face sheet that includes expiration dates, amounts of coverage and provider’s name, or evidence of compliance with Nebraska regulations regarding malpractice coverage or alternate coverage • Hospital Admitting Privileges or alternate Admitting Arrangements • Copy of current Drug Enforcement Administration (DEA) registration Certificate, and copy of state controlled substance certificate (if applicable) • Copy of W-9 • Copy of Educational Commission for Foreign Medical Graduates (ECFMG) certificate, if applicable • Curriculum vitae listing, at minimum, a five year work history (not required if work history is completed on the application) • Signed and dated release of information form not older than 90 days • Proof of highest level of education – copy of certificate or letter certifying formal post- graduate training • Copy of Clinical Laboratory Improvement Amendments (CLIA), if applicable • Disclosure of Ownership & Controlling Interest Statement • Evidence of completion of Cultural Competency training If applying as an individual practitioner or group practice, please submit the following information along with your signed participation agreement: • A completed, signed and dated Credentialing application. If applying as an ancillary or clinic provider, please submit the following information along with your signed participation agreement: • Hospital/Ancillary Provider Credentialing Application Completed (one per Facility/Ancillary Provider) • Copy of State Operational License • Copy of Accreditation/certification (by a nationally-recognized accrediting body, e.g. TJC/JCAHO)

o If not accredited by a nationally recognized body, Site Evaluation Results by a government agency. • Copy of Current General Liability coverage (document showing the amounts and dates of coverage) • Copy of Medicaid/Medicare Certification (if not certified, provide proof of participation) • Disclosure of Ownership & Controlling Interest Statement

66 • Other applicable State/Federal/Licensures (e.g. CLIA, DEA, Pharmacy, or Department of Health) • Copy of W-9 If applying as a hospital, please submit the following information along with your signed participation agreement: • Hospital/Ancillary Provider Credentialing Application Completed (one per Facility/Hospital/Ancillary Provider) • Copy of State Operational License • Copy of Accreditation/certification (by a nationally-recognized accrediting body, e.g. TJC/JCAHO) - if not accredited by a nationally-recognized body, Site Evaluation Results by a government agency • Copy of Current General Liability coverage (document showing the amounts and dates of coverage) • Copy of Medicaid/Medicare Certification (if not certified, provide proof of participation) • Disclosure of Ownership & Controlling Interest Statement • Copy of W-9 Once Nebraska Total Care has received an application, it verifies the following information, at a minimum, submitted as part of the Credentialing process (please note that this information is also re-verified as part of the re-credentialing process): • Current participation in the Nebraska Medicaid Program • A current Nebraska license through the appropriate licensing agency • Board certification, or residency training, or • National Practitioner Data Bank (NPDB) for malpractice claims and license agency actions • Hospital privileges in good standing or alternate admitting arrangements • Five year work history • Federal and state sanctions and exclusions Nebraska Total Care will complete the credentialing process within 30 days following receipt of a complete credentialing application.

CREDENTIALING COMMITTEE The Credentialing Committee is responsible for establishing and adopting as necessary, criteria for provider participation. It is also responsible for termination and direction of the credentialing procedures, including provider participation, denial and termination. Committee meetings are held at least monthly and more often as deemed necessary. Note: Failure of an applicant to adequately respond to a request for missing or expired information may result in closure of the application process prior to a committee decision.

RE-CREDENTIALING To comply with accreditation standards, Nebraska Total Care re-credentials providers at least every 36 months from the date of the initial credentialing decision. The purpose of this process is to identify any changes in the practitioner’s licensure, sanctions, certification, competence, or health status that may affect the ability to perform services the provider is under contract to provide. This process includes all providers, primary care providers, specialists and ancillary providers/facilities previously credentialed to practice within the Nebraska Total Care network.

67 In between credentialing cycles, Nebraska Total Care conducts ongoing monitoring activities on all network providers. Staff will ensure that network providers have not incurred exclusions, licensure sanctions, illegal activity, or other negative indicators in between or prior to their standard re-credentialing through this monthly monitoring. A provider’s agreement may be terminated at any time if Nebraska Total Care’ Credentialing Committee determines that the provider no longer meets the credentialing requirements.

RIGHT TO REVIEW AND CORRECT INFORMATION All providers participating within the Nebraska Total Care network have the right to review information obtained by the health plan that is used to evaluate providers’ credentialing and/or re-credentialing applications. This includes information obtained from any outside primary source such as the National Practitioner Data Bank-Healthcare Integrity and Protection Data Bank, malpractice insurance carriers and state licensing agencies. This does not allow a provider to review peer review-protected information such as references, personal recommendations, or other information. Should a provider identify any erroneous information used in the credentialing/re-credentialing process, or should any information gathered as part of the primary source verification process differ from that submitted by the provider, the provider has the right to correct any erroneous information submitted by another party. To request release of such information, a provider must submit a written request to Nebraska Total Care’s Credentialing Department. Upon receipt of this information, the provider has 14 days to provide a written explanation detailing the error or the difference in information. The Nebraska Total Care Credentialing Committee will then include the information as part of the credentialing/re-credentialing process.

RIGHT TO BE INFORMED OF APPLICATION STATUS All providers who have submitted an application to join Nebraska Total Care have the right to be informed of the status of their application upon request. To obtain status, contact your Provider Network Specialist at 1-844-385-2192, Nebraska Relay Service 711.

RIGHT TO APPEAL ADVERSE CREDENTIALING DETERMINATIONS Nebraska Total Care may decline an existing provider applicant’s continued participation for reasons such as quality of care or liability claims issues. In such cases, the provider has the right to request reconsideration in writing within 30 days of formal notice of denial. All written requests should include additional supporting documentation in favor of the applicant’s reconsideration for participation in the Nebraska Total Care network. The Credentialing Committee will review the reconsideration request at its next regularly scheduled meeting, but in no case later than 60 days from the receipt of the additional documentation. Nebraska Total Care will send a written response to the provider’s reconsideration request within two weeks of the final decision.

68 DISCLOSURE OF OWNERSHIP AND CONTROL INTEREST STATEMENT Federal regulations set forth in 42 CFR 455.104, 455.105 and 455.106 require providers who are entering into or renewing a provider agreement to disclose: • The identity of all owners with a control interest of 5% or greater • Certain business transactions as described in 42 CFR 455.105 • The identity of any excluded individual or entity with an ownership or control interest in the provider, the provider group, or disclosing entity or who is an agent or managing employee of the provider group or entity Nebraska Total Care furnishes providers with the Disclosure of Ownership and Control Interest Statement as part of the initial contracting process and again at the time of re-credentialing. This form should be completed and returned along with the signed provider agreement. If there are any changes to the information disclosed on this form, an updated form should be completed and submitted to Nebraska Total Care within 30 days of the change. Please contact Nebraska Total Care Provider Relations Department at 1-844-385-2192, Nebraska Relay Service 711 if you have questions or concerns regarding this form, or if you need to obtain another copy of the form.

69 RIGHTS AND RESPONSIBILITIES

MEMBER RIGHTS Members are informed of their rights as a Nebraska Total Care member, and our expectation that providers to respect rights. Member rights are: • To be treated with respect, dignity, and privacy. To have their rights acknowledged. • To pick or change doctors from the provider network. • To be able to get in touch with your provider. • To go to any provider or clinic for family planning services. • To get care right away if you have a medical emergency. • To be told what your illness or medical condition is. • To be told appropriate or medically necessary treatment options. To be told the alternatives that your provider thinks is best regardless of cost or benefit coverage. • To get information on treatment option in a way that you can understand, regardless of cost or coverage. • To make decisions about your health care with your provider. • To give permission before the start of diagnosis, treatment or surgery. • To refuse treatment without worrying that you will lose your coverage. • To report any complaint or grievance about your provider, medical care, your plan, or Nebraska Total Care. • To appeal action that reduces or denies services based on medical criteria. • To receive interpretation services for free in any language. • To not be pressured into making decisions about treatment. • To not be discriminated against due to race, color, national origin or health status or the need for healthcare services. • To request a second opinion. • To request disenrollment and be notified at the time of enrollment and annually of your disenrollment rights. • To make an Advance Directive. • To file any complaint with Nebraska DHHS if your Advance Directive is not followed. • To choose a provider who gives you care whenever possible and appropriate. • To receive available and accessible healthcare services similar to services given under Medicaid FFS. This includes similar amount, duration and scope. • To get enough services to be reasonable expected to achieve the goal of the treatment. • To not have your services denied or reduced just because of a specific diagnosis, type of illness or medical condition. • To use your rights without any negative effects from Nebraska DHHS, Nebraska Total Care, its providers or contractors. • To receive all written member information from Nebraska Total Care:

o At no cost to you. o In languages other than English. o In other ways, to help with the special needs of members who may have trouble reading the information for any reason • To be told that interpretation services are available and how to get them.

70 • To get help understanding the requirements and benefits of Nebraska Total Care from Nebraska DHHS and its Enrollment Broker. • To be able to get information about Nebraska Total Care plan, service, doctors and providers, and member rights and responsibilities policies. • To be able to give your ideas for Nebraska Total Care right and responsibilities policy. • If you are female, to be able to go to a woman’s health provider from the provider network for covered women’s health services. • To not be discriminated against due to race, creed, age, color, sex, religion, culture, national origin, ancestry, marital status, sexual orientation, physical or mental disability, health status or the need for healthcare services. • To have equal access to services, health programs, or activities without discrimination on the basis of gender identity and to be treat consistent with your gender identity. • To be free from any form of restraint or seclusion used as a means of coercion, discipline, retaliation, convenience or to force you to do something you do not want to do. • To talk with your doctor about your medical records. • To ask for and receive a copy of your medical records and/or a summary of your records free of charge. • To request that your medical records be changed or corrected. To have your records kept private. • To be told if the healthcare provider is a student and to be able to refuse his/her care. • To be told of any experimental care and to refuse to be part of the care.

MEMBER RESPONSIBILITIES Members are informed of their responsibilities as Nebraska Total Care members, and that treatment can be more beneficial if they meet their responsibilities. Member responsibilities are: • Notify Heritage Health if:

o Your family size changes. o You move out of the state or have other address changes. o You get or have health coverage under another policy, other third party, or there are changes to that coverage. • Work on improving your own health. • Tell Nebraska Total Care when you go to the emergency room. • Talk to your provider about preauthorization of services they recommend. • Be aware of cost-sharing responsibilities. Make payments that you are responsible for. • Inform Nebraska Total Care if your member ID card is lost or stolen. • Show your member ID card and Nebraska Medicaid ID card when getting healthcare services. • Know Nebraska Total Care procedures, coverage rules, and restrictions the best that you can. • Contact Nebraska Total Care when you need information or have questions. • Give providers accurate and complete medical information. • Follow prescribed treatment. Or tell your provider the reason(s) treatment cannot be followed as soon as possible.

71 • Ask your providers questions to help you understand treatment. Learn about the possible risks, benefits, and costs of treatment alternatives. Make care decisions after you have thought about all of these things. • Be actively involved in your treatment. Understand your health problems and be a part of making treatment goals with your provider as much as you can. • Follow the grievance process if you have concerns about your care. • Notify Nebraska Total Care, your provider, and Heritage health of changes to your address and phone number. • Treat providers and staff with respect. • Cancel appointments in advance when you can’t keep them whenever possible.

PROVIDER RIGHTS Nebraska Total Care providers have the right to: • Be treated by their patients and other healthcare workers with dignity and respect. • Receive accurate and complete information and medical histories for members’ care. • Have their patients act in a way that supports the care given to other patients and that helps keep the doctor’s office, hospital, or other offices running smoothly. • Expect other network providers to act as partners in members’ treatment plans. • Expect members to follow their directions. • File a complaint/grievance or file a claim appeal against Nebraska Total Care. File a grievance with Nebraska Total Care on behalf of a member, with the member’s consent. • File an appeal with Nebraska Total Care on the behalf of the member, with the member’s consent. • Have access to information about Nebraska Total Care quality improvement programs, including program goals, processes, and outcomes that relate to member care and services. • Contact Nebraska Total Care Provider Services with any questions, comments, or problems. • Collaborate with other healthcare professionals who are involved in the care of members.

PROVIDER RESPONSIBILITIES Nebraska Total Care providers have the responsibility to: • Help members or advocate for members to make decisions within their scope of practice about their relevant and/or medically necessary care and treatment, including the right to:

o Recommend new or experimental treatments. o Provide information regarding the nature of treatment options. o Provide information about the availability of alternative treatment options, therapies, consultations, and/or tests, including those that may be self- administered. o Be informed of the risks and consequences associated with each treatment option or choosing to forego treatment as well as the benefits of such treatment options. • Treat members with fairness, dignity, and respect. • Not discriminate against members on the basis of race, color, national origin, disability, age, religion, gender identity, mental or physical disability, or limited English proficiency.

72 • Maintain the confidentiality of members’ personal health information, including medical records and histories, and adhere to state and federal laws and regulations regarding confidentiality. • Give members a notice that clearly explains their privacy rights and responsibilities as it relates to the provider’s practice/office/facility. • Provide members with an accounting of the use and disclosure of their personal health information in accordance with HIPAA. • Allow members to request restriction on the use and disclosure of their personal health information. • Provide members, upon request, access to inspect and receive a copy of their personal health information, including medical records. • Provide clear and complete information to members, in a language they can understand, about their health condition and treatment, regardless of cost or benefit coverage, and allow the member to participate in the decision-making process. • Tell a member if the proposed medical care or treatment is part of a research experiment and give the member the right to refuse experimental treatment. • Allow a member who refuses or requests to stop treatment the right to do so, as long as the member understands that by refusing or stopping treatment the condition may worsen or be fatal. • Respect the member’s advance directives and include these documents in the member’s medical record. • Allow members to appoint a parent, guardian, family member, or other representative if they cannot fully participate in their treatment decisions. • Allow members to obtain a second opinion, and answer members’ questions about how to access healthcare services appropriately. • Follow all state and federal laws and regulations related to patient care and patient rights. • Participate in Nebraska Total Care data collection initiatives, such as HEDIS and other contractual or regulatory programs, and allow Nebraska Total Care to use performance data for quality improvement activities. • Review clinical practice guidelines distributed by Nebraska Total Care. • Comply with Nebraska Total Care Medical Management program as outlined in this handbook. • Disclose overpayments or improper payments to Nebraska Total Care. • Provide members, upon request, with information regarding the provider’s professional qualifications, such as specialty, education, residency, and board certification status. • Obtain and report to Nebraska Total Care information regarding other insurance coverage. • Notify Nebraska Total Care in writing if the provider is leaving or closing a practice. • Contact Nebraska Total Care to verify member eligibility or coverage for services, if appropriate. • Invite member participation, to the extent possible, in understanding any medical or behavioral health problems they may have and to develop mutually agreed upon treatment goals, to the extent possible. • Provide members, upon request, with information regarding office location, hours of operation, accessibility, and languages, including the ability to communicate with sign language. • Office hours of operation offered to Medicaid members will be no less than those offered to commercial members.

73 • Not be excluded, penalized, or terminated from participating with Nebraska Total Care for having developed or accumulated a substantial number of patients in the Nebraska Total Care with high cost medical conditions. • Coordinate and cooperate with other service providers who serve Medicaid members such as Head Start Programs, Healthy Start Programs, Nurse Family Partnerships and school-based programs as appropriate. • Object to providing relevant or medically necessary services on the basis of the provider’s moral or religious beliefs or other similar grounds. • Disclose to Nebraska Total Care, on an annual basis, any physician incentive plan (PIP) or risk arrangements the provider or provider group may have with physicians either within its group practice or other physicians not associated with the group practice even if there is no substantial financial risk between Nebraska Total Care and the physician or physician group. • Provide services in accordance with applicable state and federal laws and regulations and adhere to the requirements set forth in the RFP.

74 PROVIDER GRIEVANCE PROCESS A provider may file a grievance verbally or in writing at any time. A provider grievance is any provider expression of dissatisfaction regarding Nebraska Total Care policies, procedures or any aspect of Nebraska Total Care’s administrative function other than administrative review matters. This includes the process by which Nebraska Total Care handles Notice of Proposed Actions and EOPs in addition to dissatisfaction with the resolution of the Provider’s claims adjustment/claim reconsideration. All grievances/complaints are handled and process within the Grievance Department at Nebraska Total Care. Staff receiving grievances orally will acknowledge the grievance and attempt to resolve them immediately. The same process for member grievances is followed for provider grievances. Providers will receive an acknowledgment letter within ten (10) days and a resolution letter within ninety (90) days of the initial grievance notification to Nebraska Total Care. Nebraska Total Care values its providers and will not take punitive action, including and up to termination of a provider agreement or other contractual arrangements, for providers who file a grievance. Nebraska Total Care will provide assistance to providers with filing a grievance by contacting our Provider Services Department at 1-844-385-2192, Nebraska Relay Service 711 or the provider may file a grievance with any Nebraska Total Care representative. Provider grievances may be submitted by written notification to: Nebraska Total Care Attn: Grievances 2525 N 117th Ave, Suite 100 Omaha, NE 6816 FAX: 1-844-655-0567

MEMBER GRIEVANCE AND APPEAL PROCESS A member, or member-authorized representative, may file a grievance or appeal verbally or in writing at any time. A provider, acting on behalf of the member and with the member's written consent, may file a grievance or appeal. Nebraska Total Care will give members reasonable assistance in completing all forms and taking other procedural steps of the grievance and appeal system, including, but not limited to, providing translation services, communication in alternative languages and toll-free numbers with TDD/TTY and interpreter capability.

Member Grievances A member grievance is defined as any member expression of dissatisfaction. A grievance does not include matters that constitute an “action.” The grievance process allows the member, (or the member’s authorized representative acting on behalf of the member, or a provider acting on the member’s behalf with the member’s written consent, to file a grievance either orally or in writing with Nebraska Total Care. Nebraska Total Care shall acknowledge receipt of each grievance in writing. Any individuals who make a decision on grievances will not be involved in any previous level of review or decision-making. In any case where the reason for the grievance involves clinical issues or relates to denial of expedited resolution of an appeal, Nebraska Total Care shall ensure that the decision makers are health care professionals with the appropriate clinical expertise in treating the member’s condition or disease. [42 CFR § 438.406]

75 Nebraska Total Care values its providers and will not take punitive action, including and up to termination of a provider agreement or other contractual arrangements, for providers who file a grievance on a member’s behalf. Nebraska Total Care will provide assistance to both members and providers with filing a grievance by contacting our Member and Provider Services Department at 1-844-385-2192, Nebraska Relay Service 711. Acknowledgement Staff receiving grievances orally will acknowledge the grievance and attempt to resolve them immediately. Staff will document the substance of the grievance. All grievance including those received orally and resolved immediately to the satisfaction of the member, representative or provider, the staff will document the resolution details. The Grievance and Appeal Coordinator will date stamp all grievances upon initial receipt and send an acknowledgment letter, which includes a description of the grievance procedures and resolution time frames, within ten (10) calendar days of receipt. Grievance Resolution Time Frame Grievance Resolution will occur as expeditiously as the member’s health condition requires. Grievances will be resolved by the Grievance and Appeal Coordinator, in coordination with other Nebraska Total Care staff as needed. Many grievances can be resolved at the customer service level to the satisfaction of the member, representative or provider filing the grievance. Member notification of the grievance resolution shall be made in writing. Standard Grievance Resolution and notification will occur within 90 days of receipt of the grievance. Notice of Resolution The Grievance and Appeal Coordinator will provide written resolution to the member, representative or provider within the timeframes noted above. The letter will include the resolution and Nebraska MLTC requirements. The grievance response shall include, but not be limited to, the decision reached by Nebraska Total Care, the reason(s) for the decision, the policies or procedures that provide the basis for the decision, and a clear explanation of any further rights available to the member, if any. A copy of complaint and grievance logs and records of disposition shall be retained for ten years. Nebraska Total Care will provide a copy of all documents to the DHHS Medicaid Program Integrity Unit. Member Grievances may be submitted by written notification to: Nebraska Total Care Attn: Grievances 2525 N 117th Ave, Suite 100 Omaha, NE 68164 FAX: 1-844-655-0567

Appeals An appeal is the request for review of an “Adverse Benefit Determination”. An “Adverse Benefit Determination” is the denial or limited authorization of a requested service, including the type or level of service; the reduction, suspension, or termination of a previously authorized service; the denial, in whole or part of payment for a service; failure to cover or provide services in a timely manner, as defined by the Nebraska DHHS; failure to process grievance, appeals, or expedited appeals within required timeframes; or the denial of a member’s request to exercise his/her right under 42 CFR 438.52(b)(ii) to obtain services outside Nebraska Total Care network.

76 If the member is dissatisfied with the decision of Nebraska Total Care, the member, or member’s authorized representative may file a written or oral notice of appeal not more than sixty (60) calendar days of the Adverse Benefit Determination. The member appeal is acknowledged in writing within 10 business days of the receipt of a request for an appeal. The acknowledgement letter includes notification of member rights and appeal processes in a culturally and linguistically appropriate manner. The member has the right to choose additional representation by anyone, including an attorney, physician, advocate, friend or family member to represent him or her during the appeal process. The designation of their authorized representative must be submitted to Nebraska Total Care in writing. For the appeal process, Nebraska Total Care will advise the member of the right to request continuation of benefits within 10 days of the adverse benefit determination as set forth in Nebraska Total Care Appeal of Adverse Determination policy while the appeal is pending and that the member may in such a case be held liable for the cost of those benefits if the appeal is not decided in favor of member. Nebraska Total Care will provide members written notice of the reason for any extension to the timeframe for processing an appeal that is not requested by the member. Nebraska Total Care shall make reasonable efforts to provide the member with prompt verbal notice of any decisions that are not resolved wholly in favor of the member and shall follow-up within two calendar days with a written adverse benefit determination. For a standard appeal, Nebraska Total care will review, resolve and provide the enrolled and the attending or ordering provider with written or electronic notification of the appeal decision as quickly as the member’s health condition requires but no later than 30 calendar days after the request for a review. In the case of standard appeals, appeals will be resolved and the member and provider notified within 30 calendar days of receipt. The timeframe for resolution may be extended by fourteen (14) days by member request or if Nebraska Total Care provides evidence satisfactory to the DHHS that a delay in rendering a decision is in the member’s best interest. There is only one level of appeal for members. Call 1-844-385-2192, Nebraska Relay Service 711 or mail all appeals to: Nebraska Total Care Attn: Appeals 2525 N 117th Ave, Suite 100 Omaha, NE 68164 Expedited Appeals A member has the right to request an expedited appeal. Expedited appeals may be filed when Nebraska Total Care or the member’s provider determines that the time expended in a standard resolution could seriously jeopardize the member’s life or health or ability to attain, maintain, or regain maximum function. No punitive action will be taken against a provider that requests an expedited resolution or supports a member’s appeal. In instances where the member’s request for an expedited appeal is denied, the appeal must be transferred to the timeframe for standard resolution of appeals. Decisions for expedited appeals are issued as expeditiously as the member’s health condition requires, not exceeding 72 hours from the date of the Adverse Benefit Determination. Nebraska Total Care may extend this timeframe by up to an additional 14 calendar days if the member requests the extension or if Nebraska Total Care provides evidence satisfactory to the DHHS that a delay in rendering the decision is in the member’s interest. For any extension not

77 requested by the member, Nebraska Total Care shall provide written notice to the member of the reason for the delay. If Nebraska Total Care denies a request for an expedited appeal, the appeal will automatically be transferred to the standard timeframe. A reasonable attempt will be made to provide oral notification of the expedited request denial and followed up with written notice within two (2) calendar days.

State Fair Hearing Process If the member is dissatisfied with Nebraska Total Care’s decision to deny, reduce, change or terminate payment for health care services, the member can request a State Fair Hearing. Nebraska Total Care will include information in the Member Handbook, online and via the appeals process to members of their right to appeal directly to DHHS through the State Fair Hearing. A Nebraska Total Care member, or a provider acting as the member’s authorized representative, can request a State Fair Hearing only after receiving notice that Nebraska Total Care is upholding the adverse benefit determination within the Adverse Benefit Determination. Any adverse action or appeal that is not resolved wholly in favor of the member by Nebraska Total Care may be appealed by the member or the member’s authorized representative through the State Fair Hearing process for a hearing conducted in accordance with 42 CFR § 431 Subpart E. Adverse actions include reductions in service, suspensions, terminations, and denials. State Fair Hearing appeals must be requested in writing by the member or the member’s representative not more than 120 calendar days of the member’s receipt of the adverse benefit determination. Requests for a State Fair Hearing should be in writing and sent to: Nebraska Department of Health and Human Services MLTC Appeal Coordinator PO Box 94967 Lincoln, NE 68509-4967 Nebraska Total Care shall comply with the State Fair Hearing decision. The decision in these matters shall be final and shall not be subject to appeal. Reversed Appeal Resolution In accordance with 42 CFR §438.424, if Nebraska Total Care or State Fair Hearing decision reverses a decision to deny, limit, or delay services, where such services were not furnished while the appeal was pending, Nebraska Total Care will authorize the disputed services promptly and as expeditiously as the member’s health condition requires. Additionally, in the event that services were continued while the appeal was pending, Nebraska Total Care will provide reimbursement for those services in accordance with the terms of the final decision rendered by the DHHS and applicable regulations.

78 FRAUD, WASTE AND ABUSE Nebraska Total Care takes the detection, investigation, and prosecution of fraud, waste, and abuse very seriously, and has a Fraud, Waste, and Abuse (FWA) program that complies with Nebraska and federal laws. Nebraska Total Care, in conjunction with its management company, Centene, successfully operates a Special Investigations Unit (SIU). Nebraska Total Care performs front and back end audits to ensure compliance with billing regulations. Our sophisticated code editing software performs systematic audits during the claims payment process. To better understand this system please review the Provider Billing Guide found in the Provider Resources section of our website, NebraskaTotalCare.com. Nebraska Total Care performs retrospective audits, which in some cases may result in taking actions against those providers who, individually or as a practice, commit fraud, waste, and/or abuse. These actions include but are not limited to: • Remedial education and/or training to prevent the billing irregularity • More stringent utilization review • Recoupment of previously paid monies • Termination of provider agreement or other contractual arrangement • Civil and/or criminal prosecution • Any other remedies available to rectify • Unannounced Onsite Audit Investigations • Nebraska Total Care will notify DHHS Program Integrity of all provider audits Nebraska Total Care instructs and expects all its contractors and subcontractors to comply with applicable laws and regulations, including but not limited to the following: • Federal and State False Claims Act • Qui Tam Provisions (Whistleblower) • Anti-Kickback Statute • Physician Self-Referral Law (Stark Law) • HIPAA • Social Security Act • US Criminal Codes Nebraska Total Care requires all its contractors and subcontractors to report violations and suspected violations on the part of its employees, associates, persons or entities providing care or services to all Nebraska Total Care members. Examples of such violations include bribery, false claims, conspiracy to commit fraud, theft or embezzlement, false statements, mail fraud, health care fraud, obstruction of a state and/or federal health care fraud investigation, money laundering, failure to provide medically necessary services, marketing schemes, prescription forging or altering, physician illegal remuneration schemes, compensation for prescription drug switching, prescribing drugs that are not medically necessary, theft of the prescriber’s DEA number or prescription pad, identity theft or members’ medication fraud. FWA Training is available via our company website – we have a training program providers can download in PDF format. We also include FWA training in our Provider Orientation packets.

79 POST PROCESSING CLAIMS AUDIT A post-processing claims audit consists of a review of clinical documentation and claims submissions to determine whether the payment made was consistent with the services rendered. To start the audit, Centene Auditors request medical records for a defined review period. Providers have two weeks to respond to the request; if no response is received, a second and final request for medical records is forwarded to the provider. If the provider fails to respond to the second and final request for medical records, or if services for which claims have been paid are not documented in the medical record, Nebraska Total Care will recover all amounts paid for the services in question. Centene Auditors review cases for common FWA practices including: • Unbundling of codes • Up-coding services • Add-on codes billed without primary CPT • Diagnosis and/or procedure code not consistent with the member’s age/gender • Use of exclusion codes • Excessive use of units • Misuse of Benefits • Claims for services not rendered Nebraska Total Care Auditors consider state and federal laws and regulations, provider contracts, billing histories, and fee schedules in making determinations of claims payment appropriateness. If necessary, a clinician of like specialty may also review specific cases to determine if billing is appropriate. Auditors issue an audit results letter to each provider upon completion of the audit, which includes a claims report which identifies all records reviewed during the audit. If the Auditor determines that clinical documentation does not support the claims payment in some or all circumstances, Nebraska Total Care will seek recovery of all overpayments. Depending on the number of services provided during the review period, Nebraska Total Care may calculate the overpayment using an extrapolation methodology. Extrapolation is the use of statistical sampling to calculate and project overpayment amounts. It is used by Medicare Program Safeguard Contractors, CMS Recovery Audit Contractors, and Medicaid Fraud Control Units in calculating overpayments, and is recommended by the OIG in its Provider Self-Disclosure Protocol (63 Fed. Reg. 58,399; Oct. 30, 1998).

SUSPECTED INAPPROPRIATE BILLING If you suspect or witness a provider inappropriately billing or a member receiving inappropriate services, please call our anonymous and confidential FWA hotline at 1-866-685-8664. Nebraska Total Care and Centene take all reports of potential fraud, waste, and/or abuse very seriously and investigate all reported issues. NOTE: Due to the evolving nature of fraudulent, wasteful, and abusive billing, Nebraska Total Care and Centene may enhance the FWA program at any time. These enhancements may include but are not limited to creating, customizing or modifying claim edits, upgrading software, modifying forensic analysis techniques, or adding new subcontractors to help in the detection of aberrant billing patterns.

80 QUALITY IMPROVEMENT Nebraska Total Care culture, systems and processes are structured around its mission to improve the health of all enrolled members. The Quality Assessment and Performance Improvement (QAPI) Program utilizes a systematic approach to quality using reliable and valid methods of monitoring, analysis, evaluation and improvement in the delivery of healthcare provided to all members, including those with special needs. This system provides a continuous cycle for assessing the quality of care and service among plan initiatives including preventive health, acute and chronic care, behavioral health, over- and under-utilization, continuity and coordination of care, patient safety, and administrative and network services. This includes the implementation of appropriate interventions and designation of adequate resources to support the interventions. Nebraska Total Care recognizes its legal and ethical obligation to provide members with a level of care that meets recognized professional standards and is delivered in the safest, most appropriate settings. To that end, we will provide for the delivery of quality care with the primary goal of improving the health status of its members. Where the member’s condition is not amenable to improvement, Nebraska Total Care will implement measures to prevent any further decline in condition or deterioration of health status or provide for comfort measures as appropriate and requested by the member. This will include the identification of members at risk of developing conditions, the implementation of appropriate interventions and designation of adequate resources to support the interventions. Whenever possible, the Nebraska Total Care QAPI Program supports these processes and activities that are designed to achieve demonstrable and sustainable improvement in the health status of its members.

PROGRAM STRUCTURE The Nebraska Total Care Board of Directors has the ultimate authority and accountability for the oversight of the quality of care and service provided to members. The BOD oversees the QAPI Program and has established various committees and ad-hoc committees to monitor and support the QAPI Program. The Quality Assurance Performance Improvement Committee (QAPIC) is a senior management committee with physician representation that is directly accountable to the Board of Directors. The purpose of this committee is to provide oversight and direction in assessing the appropriateness and to continuously enhance and improve the quality of care and services provided to members. This is accomplished through a comprehensive, plan-wide system of ongoing, objective, and systematic monitoring; the identification, evaluation, and resolution of process problems, the identification of opportunities to improve member outcomes, and the education of members, providers and staff regarding the QI and Medical Management programs.

81 The following sub-committees report directly to the Quality Assurance Performance Improvement Committee: • Pharmacy and Therapeutics Committee • Performance Improvement Team • Provider Advisory Committee including:

o Tribal Healthcare Committee (THC), o Behavioral Health Committee (BHC), o Hospital Advisory Committee (HAC) • Clinical Advisory Committee • Utilization Management Committee • Credentialing Committee • Member Advisory Committee • Joint Operations Committees • Peer review Committee (Ad Hoc Committee)

PRACTITIONER INVOLVEMENT Nebraska Total Care recognizes the integral role practitioner involvement plays in the success of its QAPI Program. Practitioner involvement in various levels of the process is highly encouraged through provider representation. Nebraska Total Care encourages PCP, behavioral health, specialty, and OB/GYN representation on key quality committees such as but not limited to, the QAPIC and select ad-hoc committees.

QUALITY ASSESSMENT AND PERFORMANCE IMPROVEMENT PROGRAM SCOPE AND GOALS The scope of the QAPI Program is comprehensive and addresses both the quality of clinical care and the quality of service provided to the Nebraska Total Care members. Nebraska Total Care’s QAPI Program incorporates all demographic groups, care settings, and services in quality improvement activities, including preventive care, primary care, specialty care, acute care, short-term care, and ancillary services, and operations. Nebraska Total Care primary QAPI Program goal is to improve members’ health status through a variety of meaningful quality improvement activities implemented across all care settings and aimed at improving quality of care and services delivered. To that end, the Nebraska Total Care QAPI Program monitors the following: • Compliance with preventive health guidelines and practice guidelines • Acute and chronic care management • Provider network adequacy and capacity • Behavioral healthcare • Delegated entity oversight • Continuity and coordination of care • Medical Management, including under and over utilization • Compliance with member confidentiality laws and regulation • Employee and provider cultural competency • Provider appointment availability and geographic accessibility • Provider and Health Plan after-hours telephone accessibility

82 • Member experience • Provider satisfaction • Member grievance system • Provider complaint system • Member enrollment and disenrollment • Department performance and service • Patient safety • Marketing practices

PATIENT SAFETY AND QUALITY OF CARE Patient Safety is a key focus of Nebraska Total Care QAPI Program. Monitoring and promoting patient safety is integrated throughout many activities across the plan but primarily through identification of potential and/or actual quality of care events. A potential quality of care issue is any alleged act or behavior that may be detrimental to the quality or safety of patient care, is not compliant with evidence-based standard practices of care or that signals a potential sentinel event, up to and including death of a member. Nebraska Total Care employees (including medical management staff, member services staff, provider services, complaint coordinators, etc.), panel practitioners, facilities or ancillary providers, members or member representatives, Medical Directors or the BOD may advise the Quality Management (QM) Department of potential quality of care issues. Adverse events may also be identified through claims based reporting. Potential quality of care issues require investigation of the factors surrounding the event in order to make a determination of their severity and need for corrective action up to and including review by the Peer Review Committee as indicated. Potential quality of care issues received in the QM department are tracked and monitored for trends in occurrence, regardless of their outcome or severity level.

PERFORMANCE IMPROVEMENT PROCESS Nebraska Total Care QAPIC reviews and adopts an annual QAPI Program and Work Plan based on managed care Medicaid appropriate industry standards. The QAPIC adopts traditional quality/risk/utilization management approaches to problem identification with the objective of identifying improvement opportunities. Most often, initiatives are selected based on data that indicates the need for improvement in a particular clinical or non-clinical area, and includes targeted interventions that have the greatest potential for improving health outcomes or the service. Performance improvement projects, focused studies and other QI initiatives are designed and implemented in accordance with principles of sound research design and appropriate statistical analysis. These include proven methodologies such as Six Sigma and Rapid Cycle Improvements. Results of these studies are used to evaluate the appropriateness and quality of care and services delivered against established standards and guidelines for the provision of that care or service. Each QI initiative is also designed to allow Nebraska Total Care to monitor improvement over time. Annually, Nebraska Total Care develops a QAPI Work Plan for the upcoming year. The QAPI Work Plan serves as a working document to guide quality improvement efforts on a continuous basis. The work plan integrates QAPIC activities, reporting and studies from all areas of the organization (clinical and service) and includes timelines for completion and reporting to the QAPIC as well as requirements for external reporting. Studies and other performance

83 measurement activities and issues to be tracked over time are scheduled in the QAPI Work Plan. Nebraska Total Care communicates activities and outcomes of its QAPI Program to both members and providers through avenues such as the member newsletter, provider newsletter and the Nebraska Total Care web portal at NebraskaTotalCare.com. At any time, Nebraska Total Care providers may request additional information on the health plan programs including a description of the QAPI Program and a report on Nebraska Total Care progress in meeting the QAPI Program goals by contacting the Quality Management department.

HEALTHCARE EFFECTIVENESS DATA AND INFORMATION SET (HEDIS) HEDIS is a set of standardized performance measures developed by the National Committee for Quality Assurance (NCQA), which allows comparison across health plans. HEDIS gives purchasers and consumers the ability to distinguish between health plans based on comparative quality instead of simply cost differences. HEDIS reporting is a required part of NCQA Health Plan Accreditation and the Nebraska State Medicaid contract. As both the Nebraska and Federal governments move toward a that is driven by quality, HEDIS rates are becoming more and more important, not only to the health plan, but to the individual provider as well. Nebraska purchasers of healthcare use the aggregated HEDIS rates to evaluate the effectiveness of a Health Insurance Company’s ability to demonstrate an improvement in preventive health outreach to its members. Physician specific scores are being used as evidence of preventive care from primary care office practices. The rates then serve as a basis for physician incentive programs such as ‘pay for performance’ and ‘quality bonus funds’. These programs pay providers an increased premium based on scoring of such quality indicators used in HEDIS.

How are HEDIS rates calculated? HEDIS rates can be calculated in two ways: administrative data or hybrid data. Administrative data consists of claim and encounter data submitted to the health plan. Measures typically calculated using administrative data include: annual mammogram, annual chlamydia screening, appropriate treatment of asthma, antidepressant medication management, access to PCP services, and utilization of acute and mental health services, to name a few measures. Hybrid data consists of both administrative data and a sample of medical record data. Hybrid data requires review of a random sample of member medical records to abstract data for services rendered but that were not reported to the health plan through claims/encounter data. Accurate and timely claim/encounter data and submission of appropriate CPT II codes can reduce the necessity of medical record reviews (see Nebraska Total Care website and HEDIS brochure for more information on reducing HEDIS medical record reviews and improving your HEDIS scores). Measures typically requiring medical record review include: childhood immunizations, well child visits, diabetic HbA1c, eye exam and nephropathy, controlling high blood pressure, cervical cancer screening, and prenatal care and postpartum care.

84 When Will Medical Record Reviews (MRR) be completed for HEDIS? Nebraska Total Care may contract with a national MRR vendor to conduct the HEDIS MRR on its behalf. Medical record review audits for HEDIS are usually conducted March through May each year. At that time, you may receive a call from a medical record review representative if any of your patients are selected in the HEDIS samples. Your prompt cooperation with the representative is greatly needed and appreciated. As a reminder, protected health information (PHI) that is used or disclosed for purposes of treatment, payment or healthcare operations is permitted by HIPAA Privacy Rules (45 CFR 164.506) and does not require consent or authorization from the member/patient. The MRR vendor will sign a HIPAA compliant Business Associate Agreement with Nebraska Total Care, which allows them to collect PHI on our behalf.

What can be done to improve my HEDIS scores? • Understand the specifications established for each HEDIS measure. • Submit claim/encounter data for each and every service rendered. All providers must bill (or report by encounter submission) for services delivered, regardless of contract status. Claim/encounter data is the most clean and efficient way to report HEDIS. If services are not billed or not billed accurately they are not included in the calculation. Accurate and timely submission of claim/encounter data will positively reduce the number of medical record reviews required for HEDIS rate calculation. • Ensure chart documentation reflects all services provided. • Bill CPT II codes related to HEDIS measures such as diabetes, body mass index (BMI calculations, eye exam and blood pressure. If you have any questions, comments, or concerns related to the annual HEDIS project or the medical record reviews, please contact the Quality Improvement department at 1-844-385-2192, Nebraska Relay Service 711.

85 MEDICAL RECORDS REVIEW Nebraska Total Care providers must keep accurate and complete medical records. Such records will enable providers to render the highest quality healthcare service to members. They will also enable Nebraska Total Care to review the quality and appropriateness of the services rendered. To ensure the member’s privacy, medical records should be kept in a secure location. Nebraska Total Care requires providers to maintain all records for members for at least ten years. See the Member Rights section of this handbook for policies on member access to medical records.

REQUIRED INFORMATION Medical records means the complete, comprehensive member records including, but not limited to, x-rays, laboratory tests, results, examinations and notes, accessible at the site of the member’s participating primary care physician or provider, that document all medical services received by the member, including inpatient, ambulatory, ancillary, and emergency care, prepared in accordance with all applicable state rules and regulations, and signed by the medical professional rendering the services. Providers must maintain complete medical records for members in accordance with the following standards: • Member name, and/or medical record number on all chart pages. • Personal/biographical data is present (i.e., employer, home telephone number, spouse, next of kin, legal guardianship, primary language, etc.). • Prominent notation of any spoken language translation or communication assistance • All entries must be legible and maintained in detail. • All entries must be dated and signed, or dictated by the provider rendering the care. • Significant illnesses and/or medical conditions are documented on the problem list and all past and current diagnoses. • Medication, allergies, and adverse reactions are prominently documented in a uniform location in the medical record; if no known allergies, NKA or NKDA are documented. • An up-to-date immunization record is established for pediatric members or an appropriate history is made in chart for adults. • Evidence that preventive screening and services are offered in accordance with Nebraska Total Care’ practice guidelines. • Appropriate subjective and objective information pertinent to the member’s presenting complaints is documented in the history and physical. • Past medical history (for members seen three or more times) is easily identified and includes any serious accidents, operations and/or illnesses, discharge summaries, and ER encounters. • For children and adolescents (18 years and younger) past medical history relating to prenatal care, birth, any operations and/or childhood illnesses. • Working diagnosis is consistent with findings. • Treatment plan is appropriate for diagnosis. • Documented treatment prescribed, therapy prescribed and drug administered or dispensed including instructions to the member. • Documentation of prenatal risk assessment for pregnant women or infant risk assessment for newborns.

86 • Signed and dated required consent forms. • Unresolved problems from previous visits are addressed in subsequent visits. • Laboratory and other studies ordered as appropriate. • Abnormal lab and imaging study results have explicit notations in the record for follow-up plans; all entries should be initialed by the primary care provider (PCP) to signify review. • Referrals to specialists and ancillary providers are documented including follow up of outcomes and summaries of treatment rendered elsewhere including family planning services, preventive services and services for the treatment of sexually transmitted diseases. • Health teaching and/or counseling is documented. • For members 10 years and over, appropriate notations concerning use of tobacco, alcohol and substance use (for members seen three or more times substance abuse history should be queried). • Documentation of failure to keep an appointment. • Encounter forms or notes have a notation, when indicated, regarding follow-up care calls or visits. The specific time of return should be noted as weeks, months or as needed. • Evidence that the member is not placed at inappropriate risk by a diagnostic or therapeutic problem. • Confidentiality of member information and records protected. • Evidence that an advance directive has been offered to adults 18 years of age and older.

MEDICAL RECORDS RELEASE All member medical records shall be confidential and shall not be released without the written authorization of the covered person or a responsible covered person’s legal guardian. When the release of medical records is appropriate, the extent of that release should be based upon medical necessity or on a need to know basis. As a reminder, protected health information (PHI) that is used or disclosed for purposes of treatment, payment or healthcare operations is permitted by HIPAA Privacy Rules (45 CFR 164.506) and does not require consent or authorization from the member/patient. The MRR vendor will sign a HIPAA compliant Business Associate Agreement with Nebraska Total Care, which allows them to collect PHI on our behalf.

MEDICAL RECORDS TRANSFER FOR NEW MEMBER All PCPs are required to document in the member’s medical record attempts to obtain historical medical records for all newly assigned Nebraska Total Care members. If the member or member’s guardian is unable to remember where they obtained medical care, or they are unable to provide addresses of the previous providers then this should also be noted in the medical record.

FEDERAL AND STATE LAWS GOVERNMENT THE RELEASE OF INFORMATION The release of certain information is governed by a myriad of federal and/or state laws. These laws often place restrictions on how specific types of information may be disclosed, including, but not limited to, mental health, alcohol /substance abuse treatment and communicable disease records.

87 For example, the federal Health Insurance Portability and Accountability Act (HIPAA) requires that covered entities, such as health plans and providers, release protected health information only when permitted under the law, such as for treatment, payment and operations activities, including care management and coordination. However, a different set of federal rules place more stringent restrictions on the use and disclosure of alcohol and substance abuse treatment records (42 CFR Part 2 or “Part 2”). These records generally may not be released without consent from the individual whose information is subject to the release. Still other laws at the state level place further restrictions on the release of certain information such as mental health, communicable disease, etc. For more information about any of these laws, refer to following: • HIPAA - please visit the Centers for Medicare & Medicaid Services (CMS) website at cms.gov and then select “Regulations and Guidance” and “HIPAA – General Information” • Part 2 regulations - please visit the Substance Abuse and Mental Health Services Administration (within the U.S. Department of Health and Human Services) at samhsa.gov • State laws - consult applicable statutes to determine how they may impact the release of information on patients whose care you provide. Contracted providers within our network are independently obligated to know, understand and comply with these laws. We take privacy and confidentiality seriously. We have established processes, policies and procedures to comply with HIPAA and other applicable federal and/or State confidentiality and privacy laws. Please contact the Nebraska Total Care Privacy Officer at 1-844-385-2192, Nebraska Relay Service 711 or in writing (refer to the address below) with any questions about our privacy practices. Nebraska Total Care Attn: Compliance Department 2525 N 117th Ave, Suite 100 Omaha, NE 68164

© 2017 Nebraska Total Care, rev. 9/2021 NebraskaTotalCare.com Customer Service: 1-844-385-2192, Nebraska Relay Service 711

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